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RJ496.P2  B66  Acute  poliomyelitis 


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Boudreau,   F.   G, 


Acute  ?o3.iomyelitis 


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ACUTE  POLIOMYELITIS 

With  Specizil  Reference  to  the  Disease  in  Ohio, 
£uid  Cert£un  Transmission  Elxperiments 

Reprinted  from  Monthly  Bolletin,  Ohio  State  Board  of  Health,  January,  February  and  March,  1914 


F.  G.  BOUDREAU,  M.D.,  CM. 
and  CHAS.  K.  BRAIN,  F.E.S. 


In  Collaboration  with 


E.  F.  McCAMPBELL,  Ph.D.,  M.D. 

Staff  Ohio  State  Board  of  Health 


MEMBERS  OF  THE  STATE  BOARD  OF  HEALTH. 

John  W.  Hill,  C  K,  President Cincinnati. 

H.  T.  Sutton,  M.  D.,  Vice-President Zanesville. 

JosiAH  Hartzell,  Ph.  D Canton. 

R.  H.  Grote,  M.  D Xenia. 

WnLLAM  T.  Meller,  M.  D Cleveland. 

Homer  C.  Brown,  D.  D.  S Columbus. 

Oscar  Hasencamp,  M.  D Toledo. 

I 

OFFICIAL  STAFF. 

DIVISION  OF  ADMINISTRATION. 

Eugene  F.  McCampbell,  Ph.  D.,  M.  D Secretary  and  Executive  Officer. 

James  E.  Bauman,  Esq Assistant  Secretary. 

DIVISION  OF   SANITARY  ENGINEERING. 

W.  H.  Dittoe,  Cer.  Engr Director  and  Chief  Engineer,  i 

M.  Z.  Bair Assistant  Engineer.  I 

L.  H.  Van  Buskirk,  B.  S. Assistant  Engineer.  > 

Harold  G.  McGee,  B.  C.  E ' Assistant  Engineer. 

DIVISION  OF  HYGIENIC  LABORATORIES. 

T.  R.  Brown,  Ph.  D Director  and  Bacteriologist. 

Fred  Berry,  M.  A Assistant  Bacteriologist.  > 

Martha  Koehne,  M.  A - Chemist.  ■ 

J.  J.  Coons,  M.  D Pathologist.  } 

DIVISION    OF    PUBLIC    HEALTH    EDUCATION    AND    TUBERCULOSIS,  j 

Robert  G.  Paterson,   Ph.   D Director 

Superintendent  of  Publications. 

W.  E.  Spencer Superintendent  of  Health  Exhibit. 

Mary  Louise  Mark,  M.  A Statistician. 

Sara  Kerr,  B.  A Assistant  Statistician. 

Marg.\ret  Kamerer,  R.  N Supervising  Nurse. 

Catherine  McNamara,  R.  N Visiting  Nurse. 

DIVISION   OF  OCCUPATIONAL  DISEASES. 

E.  R.  Hayhurst,  M.  D Director  of  Survey.  | 

DIVISION  OF  COMMUNICABLE  DISEASES.  1 

F.  G.  Boudreau,  M.  D Director  and  Epidemiologist.  \ 

Assistant  Epidemiologist. 

DIVISION  OF  PLUMBING  INSPECTION. 

William  C.  Gsoeniger Director  and  State  Inspector 

Deputy  State  Inspector 

OfRces  of  the  Board  are  in  Page  Hall,  Ohio  State  University  Campus.     Labora, 
tories   are  temporarily   located   in   the   Hartman   Building,   Columbus.  / 


Acute  Poliomyelitis 


With  Special  Reference    to  the  Disease  in  Ohio, 
and  Certain  Transmission   Experiments 


F.  G.   BOUDREAU,  M.   D.,  C.   M.,  and 
C.  K.  BRAIN,  F.  E.  S. 

In   Collaborac  on   with 

E.  F.  McCAMPBELL,  Ph.  D.,  M.  D. 

Staff   Ohio  State    Board   of   Heahh 


Reprinted  from   Monthly  Bulletin  Ohio  State  Board  of   Health, 
January.  February  and    March,  1914 


Columbus,  Ohio  : 
The  F.  j.  Heer  Printing  Co.  , 

1914 


ItG 


ACUTE   POLIOMYELITIS, 

With  Special  Reference  to  the  Disease  in  Ohio,  and  Certain 
Transmission  Experiments. 

F.  G.  BouDREAu,  M.  D.,  C.  M.,  and  Chas.  K.  Brain,  F.  E.  S. 

Tn  Collaboration  with 

E.  F.  McCampbell,  Ph.  D.,  M.  D. 

Staff  Ohio  State  Board  of  Health. 

CONTENTS. 

Introduction   3 

Occurrence  in  Ohio 0 

Etiology  7 

Experiments  in   Transmission 17 

Epidemiology    42 

Etiological  factor  4!) 

Pathology    .51 

Symptomatology   :^7, 

The  Blood 70 

The  Cerebrospinal  Fluid 70 

Diagnosis    71 

Prognosis  72 

Treatment   7'! 

Prevention   7G 

INTRODUCTION. 
During  recent  years  the  attention  of  medical  men  and  public 
health  workers,  as  well  as  the  public  in  general,  has  been  attracted 
to  the  occurrence  of  a  rather  definite  infectious  and  contagious  dis- 
ease, epidemic  in  character,  known  as  acute  poliomyelitis  or  infantile 
paralysis.  This  disease  causes  the  death  and  incapacitation  of  many 
children  and  young  adults.  It  is  insidious  in  its  onset,  paralysis  often 
developing  within  a  few  hours.  In  many  instances  abortive  types  of 
the  disease  occur  which  are  highly  infectious  for  others  but  which 
do  not  develop  paralytic  symptoms.  The  disease  is  known  under 
a  variety  of  other  names  such  as  acute  anterior  poliomyelitis,  epidemic 
poliomyelitis,  acute  spinal  paralysis,  acute  atrophic  spinal  paralysis, 
essential  paralysis,  Heine-Medin  disease,  and  by  several  other  terms. 
The  term  infantile  paralysis,  first  used  by  Heine,  is  rather  ob- 
jectionable as  the  disease  does  not  always  occur  in  infants,  consequently, 
the  more  definite  term  "acute  poliomyelitis"  should  be  used.  This 
disease  is  not  in  any  sense  new.  We  have  evidences  from  examina- 
tions of  Egyptian  mummies  that  it  occurred  as  early  as  3700  B.   C. 


4  MONTHLY    BULLETIN 

The  first  description  of  the  disease  was  given  by  Underwood  in  1774, 
but  this  description  was  not  at  all  dear  and  concise  and  was  in  some 
degree  inaccurate.  It  was  not  until*  1840  that  the  clinical  symptoms 
of  the  disease  were  clearly  described  and  the  condition  differentiated 
from  certain  other  disease  conditions.  This  description  was  written 
by  Jacob  von  Heine.  Since  this  time  many  epidemics  of  this  disease 
have  occurred  and  have  been  described  by  various  writers.  Gradually, 
the  methods  of  diagnosis  have  been  perfected  and  more  exact  knowl- 
edge has  been  accumulated  in  regard  to  its  various  forms.  Heine 
studied  the  records  of  large  numbers  of  children  suffering  from 
paralysis  and  separated  a  group  in  which  the  paralysis  was  distinctly 
flaccid  in  character  with  distinct  atrophy,  the  paralysis  being  of  spinal 
origin.  Recent  investigations,  however,  have  shown  that  Heine's 
limitations  in  the  group  of  cases  which  he  selected  were  not  broad 
enough  and  that  numerous  cases  of  acute  poliomyelitis  occurred, 
especially  of  the  cerebral  type,  which  were  not  included  in  his  classifi- 
cation. He  undoubtedly  cal'ed  attention  to  the  most  common  type 
of  this  disease  and  his  description  of  the  symptomatology  of  chronic 
poliomyelitis  is  particularly  accurate. 

Kennedy,  in  1850,  investigated  a  large  number  of  cases  of 
"temporary  paralysis"  occurring  in  England.  There  seems  to  have 
been  some  question  as  to  whether  these  cases  were  due  to  the  same 
causes  as  those  described  by  Heine.  Following  this  early  work 
little  of  consequence  was  contributed  by  investigators  of  this  disease 
until  1890.  In  the  meantime  Duchenne  and  Erb  had  made  some 
observations  relative  to  the  faradic  reactions  of  the  muscles  and  Erb 
had  also  formulated  his  theory  of  "reaction  of  degeneration"  based 
on  studies  of  cases  of  this  disease.  Later  Striimpell  made  some  ex- 
tensive investigations  which  indicated  that  a  group  of  cerebro-palsies 
should  be  included  in  the  sam.e  group  with  spinal  palsies.  Some  time 
later,  in  1890,  Medin  made  rather  extended  studies  during,  the  occur- 
rence of  an  extensive  epidemic  of  this  disease  in  Sweden.  During 
the  course  of  this  epidemic  he  was  able  to  classify  various  types  of 
acute  poliomyelitis  and  to  establish  certain  relationships  between  them. 
This  observer  was  probably  the  first  to  describe  the  acute  stage  of 
the  disease  which  we  know  to  be  so  distinctly  characteristic.  In 
1905  Wickman  made  extensive  histological  studies  and  also  described 
the  cerebral  form  of  the  disease  and  the  abortive  types.  He  estab- 
lished the  contagious  nature  of  the  infection.  Since  Wickman's  time, 
as  previously  indicated,  many  scientific  studies  have  been  made  of  this 
disease. 

The  disease  has  been  rather  prevalent  in  Ohio  and  in  this  country 


OHIO    STATE    BOARD    OF    HEALTH.  0 

.during  the  last  few  years.  It  has  been  thought  highly  advisable  to 
present  a  rather  extended  and  comprehensive  discussion  of  this  sub- 
ject for  the  use  of  the  medical  practitioners  and  the  public  health 
workers  of  the  state.  Experiments  have  al'so  been  conducted  by  cer- 
tain members  of  the  staff  of  the  State  Board  of  Health  in  an  effort 
to  determine  how  the  disease  is  transmitted.  These  experiments  are 
recorded  somewhat  in  detail  on  the  subsequent  pages  of  this  report. 
The  epidemiology,  pathology,  symptomatology,  diagnosis  and  treat- 
ment are  also  given  due  consideration.  Especial  emphasis  has  been 
placed  upon  the  preventive  measures  to  be  used  in  the  control  of  this 
disease.  The  measures  which  are  outlined  have  been  found  to  be 
distinctly  successful  in  controlling  this  infection. 

The  fact  that  acute  poliomyelitis  or  infantile  paralysis  has  in 
the  last  decade  become  a  disease  of  world-wide  distribution,  has 
stimulated  a  host  of  workers,  who  have  added  in  large  measure  to 
our  knowledge  of  its  pathology,  etiology  and  modes  of  transmission. 
The  disease  has  been  known  in  Europe  for  many  years,  but  not  until 
1905  did  it  command  wide  attention,  for  its  occurrence  previous  to 
that  date  was  sporadic  and  infrequent;  since,  it  has  been  endemic 
and  epidemic.  This  increased  incidence  has  influenced  the  literature 
to  a  degree,  but  it  is  impossible  to  secure  in  text-books  a  knowledge 
of  the  more  recent  and  striking  advances.  In  1910  an  increasing 
number  of  sporadic  cases  in  Ohio  prophesied  the  occurrence  of  the 
disease  in  epidemic  form,  and  this  prophecy  has  been  amply  fulfilled. 
This  report  embodies  such  information  as  will  be  helpful  to  health 
officers  and  physicians,  together  with  a  study  of  the  disease  in  Ohio, 
and  is  based  upon  the  semi-monthly  reports  submitted  to  the  office 
of  the  Secretary  of  the  State  Board  of  Health  by  all  cities,  villages 
and  townships,  together  with  an  analysis  of  the  histories  of  one  hun- 
dred and  forty  cases,  fifty-two  of  which  were  taken  by  one  of  us 
(F.  G.  B.),  and  the  remainder  by  a  number  of  physicians  in  various 
parts  of  the  state.  Owing  to  certain  difficulties,  easily  appreciated 
by  those  with  experience  in  this  line  of  work,  some  of  the  histories 
are  not  as  complete  as  might  be  desired.  One  of  the  most  serious 
obstacles  encountered  was  the  impossibility  of  observing  a  large  num- 
ber of  cases  during:  the  pre-paralytic  and  the  acute  stages  of  the  dis- 
ease. Usually  when  information  as  to  the  occurrence  of  an  out- 
break was  received  the  patients  were  found  to  be  recovering  from 
a  paralvsis,  and  it  was  necessary  to  secure  a  history  of  the  prodro- 
mata  and  the  acute  stage  from  the  parents.  The  purely  epidemio- 
logical side  is  of  great  interest  at  the  present  time,  inasmuch  as  the 
work  of  Rosenau  and  Brues  (i),  and  Anderson  and  Frost  (2)  would 


6  MONTHLY    BULLETIN 

seem  to  support  the  theory  of  transmission  of  the  disease  by  the 
stable  fly  (Stomoxys  calcitrans  Linn.),  while  a  mass  of  evidence 
from  the  field  and  laboratory  tends  to  emphasize  the  view  that  the 
disease  is  transmissible  by  personal  contact  as  originally  held  by 
Wickman,  and  recently  brought  into  the  foreground  by  the  experi- 
ments of  Kling,  Pettersson  and  Werndstedt  in  Sweden  (3),  and  by 
Flexner  and  Clark  (4)  in  this  country. 

ACUTE    POLIOMYELITIS    IN    OHIO. 

By  action  of  the  State  Board  of  Health,  acute  poliomyelitis  was 
made  a  reportable  disease  in  Ohio  in  December,  1910.  Previous  to 
this  the  disease  had  occurred  sporadically,  but  there  is  no  evidence 
to  prove  its  existence  in  epidemic  form  until  191 1.  According  to  the 
report  of  the  Bureau  of  the  Census,  1910  (109)  (5),  seventy-six 
deaths  from  poliomyelitis  occurred  in  Ohio  in  1910,  and  the  larger 
cities  reported  the  following  deaths :  Cleveland  six,  Cincinnati  two, 
Columbus  one,  Toledo  one,  Dayton  one.  In  191 1  one  hundred  and 
forty-two  deaths  occurred  (6).  They  were  divided  among  the  cities 
as  follows :  Cleveland  fifteen,  Cincinnati  forty-one,  Columbus  four, 
Toledo  three,  Dayton  two. 

In  various  communities  a  few  cripples  have  been  found,  evidently 
the  victims  of  a  previous  attack  of  poliomyelitis,  but  there  is  little 
or  no  evidence  to  support  the  contention  that  the  number  of  cases  in 
1911  and  1912  has  been  equalled  in  the  past.  The  presumptive  evi- 
dence is  convincing  that  the  disease  did  not  prevail  to  any  extent  prior 
to  1911.  In  that  year  Cleveland  and  Cincinnati,  the  two  largest  cities 
in  Ohio,  experienced  what  may  be  properly  called  epidemics  of  acute 
poliomyelitis.  Cincinnati  suffered  the  most,  having  the  largest  num- 
ber of  cases,  and  the  onset  and  decline  of  the  outbreak  were  more 
rapid  and  the  course  more  acute  than  was  the  case  in  Cleveland. 
For  several  weeks  the  number  of  deaths  from  this  cause  outnumbered 
deaths  from  all  other  communicable  diseases  combined. 

Cincinnati.  The  outbreak  in  Cincinnati  was  preceded  by  an 
epidemic  in  Covington,  Kentucky,  a  description  of  which,  unfor- 
tunately, cannot  be  included  here.  Immediately  following  the  height 
of  this  outbreak,  cases  began  to  develop  in  Cincinnati  as  follows : 

Months.  Cases.  Deaths. 

September  2  2 

October  69  21 

November   27  14 

December   5  4 

103  41 


OHIO    STATE    BOARD    OF    HEALTH.  't 

From  ninety  to  ninety-five  per  cent,  of  the  cases  were  under  six 
years  of  age,  with  the  large  majority  between  one  and  two  years  of 
age.  No  particular  focus  of  infection  was  discovered,  nor  did  the 
outbreak  appear  to  bear  any  relation  to  public  schools. 

Cleveland.  In  Cleveland  fifty-five  cases  were  reported  in  191 1, 
the  first  appearing  on  January  4th.  Only  a  few  additional  sporadic 
cases  were  reported  until  September.  On  the  19th  of  September  five 
cases  developed  and  from  that  time  the  disease  assumed  epidemic  pro- 
portions. Over  seventy-two  per  cent  of  the  cases  Avere  under  five 
vears  of  age.     Death  occurred  in  fifteen  instances. 

OCCURREXCE   IX   OHIO   IN    I912. 

In  1912  acute  poliomyelitis  began  to  appear  in  January,  but  pre- 
vailed only  in  sporadic  form  until  June,  when  an  increase  in  the 
number  of  cases  took  place.  In  all  three  hundred  and  fifty-four 
cases,  were  reported  to  the  office  of  the  Secretary  of  the  State  Board 
of  Health.  The  disease  was  epidemic  in  Barberton,  Dayton  and  Cleve- 
land. The  rate  of  occurrence  per  capita  in  Barberton  was  by  far  the 
highest.  Cases  were  reported  from  fifty-four  of  the  eighty-eight 
counties  in  Ohio. 

ETIOLOGY. 

The  etiology  or  cause  of  acute  poliomyelitis  has  not  been  definitely 
determined.  The  nature  and  life  history  of  the  parasite  is  not  well 
understood,  and  the  predisposing  causes,  if  any,  which  determine 
infection,  have  not  as  yet  been  discovered.  V\'e:  know  that  the  para- 
site or  virus  is  a  living  organism  because  it  is  capable  of  multiplica- 
tion. It  is,  however,  ultra-microscopic  and  filterable,  passing  readily 
through  the  fine  pores  of  a  Berkfeld  or  Chamberland  filter,  and 
therefore  belonging  to  that  class  of  parasites  which  include  those  of 
vaccinia,  yellow  fever  and  foot  and  mouth  disease.  The  parasite  has 
recently  been  cultivated  in  vitro  by  Flexner  and  Noguchi  (7),  and 
this  affords  us  reason  to  hope  that  its  natural  history  will  be  eluci- 
dated in  the  near  future. 

For  many  centuries  the  nature  of  the  disease  itself  was  not 
definitely  known.  Wickman  (8)  in  1905,  basing  his  conclusion  upon 
the  study  of  a  large  number  of  cases,  suggested  its  infectious  nature 
and  this  was  definitely  proved  by  Landsteiner  and  Popper  (9),  and 
by  Flexner  and  Clark  (10)  in  1909.  We  know  of  no  disease  occur- 
ring: in  epidemic  form  which  is  not  infectious.  The  fact  that  the 
disease  was  contagious  was  also  pointed  out  by  Wickman  in  1905. 
and   his  conclusion  was  based  upon   a   study  of  the  largest  number 


8  MONTHLY    BULLETIN 

of  cases  that  had  been  observed  up  to  that  time.  He  stated  that 
the  infection  was  transmissible  by  personal  contact,  and  that  the 
school  was  the  focus  of  infection  in  each  village.  His  most  im- 
portant contribution  was  his  recognition  of  abortive  cases  of  the 
disease.  By  means  of  these  cases  he  was  able  to  show  the  relation 
between  typical  or  paralyzed  cases.  In  his  opinion,  infected  rooms, 
houses  and  articles  (fomites)  in  close  contact  with  cases,  played  an 
important  part  in  the  transmission  of  the  disease,  constituting  so  to 
soeak,  a  link  in  the  chain  of  contact  between  a  patient  and  a  sus- 
ceptible individual.  Those  who  have  studied  the  modes  of  trans- 
mission of  the  various  communicable  diseases  must  appreciate  the 
importance  of  recent  information  which  has  been  collected  on  this 
subject.  Fomites,  that  is,  inanimate  objects  in  a  distant  or  close 
relationship  to  patients,  have  little  influence  in  the  transmission  of 
communicable  diseases.  Personal  contact  with  carriers  of  Avhatever 
nature,  including  typical,  missed,  abortive,  and  atypical  cases,  is  the 
important  factor.  The  obloquy  thrown  upon  terminal  disinfection  by 
Chapin,  Doty  and  many  others,  and  the  rejection  of  the  "defective 
drainage"  theory  and  like  hypotheses  of  the  transmission  of  scarlet 
fever  and  diphtheria,  is  evidence  of  the  ground  gained  by  the  pro- 
ponents of  this  new  conception.  In  other  words,  the  human  host 
is  the  most  important  factor  in  the  transmission  of  the  acute  infectious 
diseases;  and  inanimate  objects,  with  the  exception  of  those  which 
have  been  in  extremely  intimate  contact  with  the  patient,  are  almost 
negligible  as  sources  of  disease.  The  view  that  acute  poliomyelitis 
i.s  contagious  has  been  gradually  gaining  ground  among  those  most 
familiar  with  the  disease,  although  the  large  mass  of  clinicians  who 
see  only  isolated  and  sporadic  cases  are  still  unconvinced.  It  has 
been  pointed  out  by  the  opponents  of  this  theory  that  the  percentage 
of  second  cases  in  a  family  is  small,  but  this  argument  can  be  met 
with  two  statements,  —  first,  that  many  abortive  cases  of  acute 
Doliomyelitis  occur  and  are  not  recognized,  and  second,  many  indi- 
viduals are  not  susceptible  to  acute  poliomyelitis  and  many  other 
transmissible  diseases  with  the  exception  of  smallpox  and  measles, 
which  flourish  in  any  soil.  Typhoid  fever  has  only  come  to.be  con- 
sidered a  contagious  disease  in  recent  years,  and  the  percentage  of 
secondary  cases  in  a  family  is  also  low ;  but  the  evidence  is  con- 
vincing that  transmission  by  contact  in  some  epidemics,  and  especially 
in  semi-tropical  states,  is  an  important,  if  not  the  important  method 
of  transmission.  In  acute  poliomyelitis,  as  in  epidemic  cerebro-spinal 
meningitis,  many  people  —  a  large  majority  of  the  population,  appear 
to  be  insusceptible.     A  further  reason  why  the  contagious  nature  of 


OHIO   STATE    BOARD   OF    HEALTH.  9 

acute  poliomyelitis  cannot  be  disproved  is  that  we  do  not  know 
how  numerous  are  healthy  carriers  and  missed  and  abortive  cases. 
One  observer  has  suggested  that  epidemic  cerebro-spinal  meningitis 
is  a  common  disease  of  childhood,  which  only  in  an  extremely  limited 
number  of  cases  localizes  in  the  central  nervous  system  and  gives 
rise  to.  the  manifestations  which  we  regard  as  characteristic  of  the 
disease;  and  this  suggestion  may  also  be  true  of  acute  poliomyelitis. 
A  very  important  step  was  taken  when  the  virus  was  found  to  exist 
in  the  nasal  mucosa  of  acute  cases.  Kling,  Pettersson  and  Wernstedt 
(3)  were  able  to  go  a  step  further  and  prove  that  the  virus  existed 
in  the  secretions  of  the  nasopharnyx,  trachea  and  intestines.  This 
was  true  not  only  of  acute  cases  dead  of  the  disease,  but  in  living  cases 
after  recovery,  in  abortive  cases  and  in  healthy  individuals,  including 
those  in  intimate  contact  with  the  disease,  and  those  in  whom  no 
contact  had  taken  place.  This  work  was  soon  afterward  confirmed 
by  Flexner  and  Fraser  (11),  who  were  able  to  prove  conclusively 
that  the  disease  transmitted  in  this  manner  was  true  poliomyelitis,  by 
using  the  spinal  cords  for  inoculation  experiments,  Avhich  were  suc- 
cessful. Flexner  (12)  had  previously  shown  that  the  virus  gained 
entrance  to  the  central  nervous  system  from  the  nasopharnyx,  along 
lymphatic  paths  accompanying  the  fine  filaments  of  the  olfactory 
nerves,  and  this,  in  connection  with  the  work  mentioned  above, 
renders  the  chain  of  circumstantial  evidence  as  to  the  contagious 
nature  of  acute  poliomyelitis  most  complete.  What  light  these  ob- 
servers have  thrown  upon  the  modes  of  transmission  will  be  dealt 
with  in  detail  when  the  epidemiology  of  the  disease  is  discussed. 

GEOGRAPHICAL   DISTRIBUTION. 

Only  within  recent  years  has  acute  poliomyelitis  become  pandemic. 
Previous  to  1907  the  disease  had  been  epidemic  in  Northern  Europe 
for  many  years,  but  since,  it  has  prevailed  most  extensively  in  North 
America.  No  explanation  of  this  movement  '  is  forthcoming, 
although  the  influence  of  the  Scandinavian  epidemic  is  said  to  have 
been  felt  in  America,  through  the  great  increase  of  immigration 
from  Northern  Europe.  This  question  will  be  discussed  at  greater 
length  subsequently.  Acute  poliomyelitis  prevails  rather  in  temper- 
ate than  in  tropical  zones,  although  the  latter  are  not  altogether 
spared.  The  disease  has  occurred  in  Cuba.  The  first  recorded  out- 
break in  America  occurred  in  Louisiana,  and  was  described  by  Colmer 
in  1843  (13)-  Not  until  190/  were  further  outbreaks  recorded  in 
America.  Since  that  date  the  number  of  cases  has  greatly  increased 
year  by  year,  and  the  number  and  size  of  outbreaks  has   also  in- 


10 


MONTllIV    BULLETIN 


creased.  England  did  not  share  in  the  general  increased  incidence 
until  1909,  and  the  disease  did  not  assume  serious  proportions  there 
until  191 1.  The  most  severe  outbreak  occurred  in  Devon  and  Corn- 
wall, in  191 1,  and  comprised  two  hundred  and  fifty  cases.  In  this 
connection  it  is  interesting  to  observe  that  until  recent  years  England 
escaped  to  a  large  extent  the  ravages  of  epidemic  meningitis  which 
prevailed  in  France  and  Northern  Europe,  and  in  North  America  dur- 
ing the  late  years  of  the  nineteenth  and  early  years  of  the  twentieth 
centuries. 

SEASONAL   PREVALENCE. 

Acute  poliomyelitis  possesses  a  well  marked  seasonal  prevalence 
in  northern  countries  and  temperate  zones,  where  it  occurs  in  the 
warm  months.  It  occurs  also  in  the  tropics  at  the  height  of  the>  sum- 
mer season.  The  seasonal  distribution  of  the  disease  in  Ohio  corre- 
sponds closely  to  that  found  by  other  observers  elsewhere.  A  table 
showing  the  comparative  distribution  follows : 

TABLE  OF   CASES   BY    MONTHS. 


Ohio. 

Sinkler. 

Starr. 

Lovett. 

Cases. 

Cases. 

Cases. 

Cases. 

January   

7 
2 

3 

1 
1 

19 
52 
75 
95 
59 
31 
9 

14 

8 
11 
•21 
21 
61 
109 
124 
79 
45 
12 
12 

5 

2 

9 

4 

5 

10 

42 

57 

41 

18 

6 

3 

8 

February       

4 

March   

5 

April   

5 

May 

6 

June     

13 

Tulv   

36 

August       

43 

September    

47 

October   

39 

November    

29 

December    

4 

354 

517 

202 

239 

From  this  table  it  is  evident  that  in  Ohio  the  disease  prevailed 
from  the  first  of  June  to  the  end  of  October.  July,  August,  Septem- 
ber and  October  show  the  greatest  prevalence  in  temperate  zones. 


DISTRIBUTION    ACCORDING   TO   DENSITY    OF    POPULATION. 

Acute  poliomyelitis  is  said  to  be  a  rural  rather  than  an  urban 
disease  and   statistics   from  ^  many   countries   and   states   support  this 


OHIO    STATE    BOARD    OF    HEALTH.  11 

contention.  Of  the  three  hundred  and  fifty-four  cases  in  Ohio,  one 
hundred  and  forty-nine  cases  occurred  in  cities  having  a  population 
of  one  hundred  thousand  or  over;  five  cases  occurred  in  cities  having 
a  population  of  over  fifty  thousand  or  less  than  one  hundred  thou- 
sand; nine  cases  occurred  in  cities  having  a  population  of  over  twenty- 
five  thousand  and  less  than  fifty  thousand;  sixty-nine  cases  occurred 
in  incorporated  villages;  one  hundred  and  twenty-one  cases  occurred 
in  townships  and  non-incorporated  villages. 

It  is  evident  that  many  more  cases  were  reported  from  cities  in 
Ohio  than  from  rural  communities.  In  drawing  any  conclusions  from 
these  figures  it  must  be  borne  in  mind  that  in  cities  boards  of  health 
are  better  organized  and  have  greater  police  power,  or  at  least  are 
able  to  utilize  police  power  to  greater  advantage  than  is  possible  in 
country  districts.  In  cities  physicians  are  in  the  habit  of  reporting 
cases,  and  have  greater  facilities  for  so  doing  than  is  the  case  with 
the  country  physician.  Further  information  concerning  the  advent 
and  nature  of  any  rare  disease  is  more  easily  and  rapidly  circulated 
in  cities.  The  value  of  comparative  statistics  of  rural  and  urban 
districts  must,  therefore,  be  subject  to  a  considerable  discount. 

RAINFALL. 

Deficient  precipitation  has  been  suggested  as  having  some  in- 
fluence upon  the  incidence  of  acute  poliomyelitis,  but  in  view  of  the 

small  amount  of  data  accumulated  and  its  inconclusiveness,  the  im- 
portance of  this  factor  must  remain  for  the  present  rather  problem- 
atical. Dust  has  been  suggested  as  a  means  of  transmitting  the  virus, 
and  deficient  precipitation  would  heighten  the  importance  of  this 
factor,  had  it  any  influence  upon  the  spread  of  acute  poliomyelitis. 
In  general  it  may  be  said  that  no  proof  has  been  adduced  of  any  con- 
vincing nature  of  the  relationship  between  deficient  precipitation  and 
the  incidence  of  acute  poliomyelitis. 

Altitude  appears  to  bear  no  relation  to  the  incidence  of  acute 
poliomyelitis. 

CONSTITUTIONAL   PREDISPOSITION. 

It  is  not  known  whether,  as  in  the  case  of  scarlet  fever  or 
diphtheria,  the  presence  of  a  catarrhal  condition  of  the  site  of  en- 
trance of  the  causative  organism  render  the  individual  so  affected 
more  subject  to  infection  with  acute  poliomyelitis.  In  common  with 
these  two  acute  diseases  it  is  probable  that  the  virus  gains  entrance 
by  means  of  the  nasopharyngeal  mucosa,  and  it  would  be  logical  to 
suppose  that  a  pathological  condition  of  this  membrane  would  render 


12  MONTHLY    BULLETIN 

an  individual  more  susceptible  to  infection.  No  definite  statement  as 
to  the  truth  or  falsity  of  this  conception  can  be  ventured  at  the 
present  time.  The  work  of  Osgood  and  Lucas  (14)  on  the  presence 
of  the  virus  of  acute  poliomyelitis  in  the  tonsillar  mucosa  is  suggestive 
in  this  connection. 

A  remarkable  feature  of  our  cases  was  the  previous  healthy  con- 
dition of  the  patients  as  shown  in  the  following  table : 

PREVIOUS   HEALTH. 

Excellent.  Good.  Poor. 

52  7(3  12 

One  of  the  characteristics  of  the  disease  appears  to  be  that  an 
individual,  previously  in  excellent  health,  is  suddenly  stricken  with  a 
feverish  condition  while  engaged  in  active  play  and  subsequently  be- 
comes paralyzed.  The  suddenness  of  both  these  events  is  remarkable 
and  startling,  especially  when  no  other  cases  are  known  to  exist  in 
the  community. 

Accidents  or  Illness  Preceding  Attack.  Trauma  has  been  fre- 
quently reported  in  connection  with  cases  of  acute  poliomyelitis.  This 
was  commented  upon  by  Starr  (16),  who  considered  that  inasmuch 
as  a  vascular  disturbance  is  the  fundamental  change  in  the  disease,  the 
influence  of  trauma  might  be  considerable.  Trauma  may  set  up  a 
paralysis  simulating  acute  poliomyelitis,  but  its  rarity  and  the  absence 
of  the  more  or  less  characteristic  constitutional  disturbances,  as  well 
as  the  character  of  the  paralysis,  should  serve  to  differentiate  it  from 
acute  poliomyelitis.  In  our  opinion  the  part  played  by  trauma  has 
been  greatly  exaggerated,  and  in  none  of  our  cases  was  there  any 
possibility  that  trauma  could  act  other  than  as  a  predisposing  factor. 

In  fourteen  of  our  cases,  a  fall  of  some  kind  occurred  during  the 
week  preceding  the  attack.  In  two  of  these  the  fall  occurred  on  the 
same  day  as  the  onset.  In  the  twelve  others,  the  fall  occurred  during 
the  week  preceding  the  onset.  In  no  other  cases  was  there  a  history 
of  trauma  during  the  month  preceding  the  attack. 

Illness  Preceding  Attack.  That  there  is  an  intimate  relation  be- 
tween acute  poliomyelitis  and  some  of  the  acute  diseases  of  childhood 
is  believed  by  some  observers.  Starr  (15)  states  that  in  his  own 
cases,  diphtheria,  meningitis,  pneumonia,  scarlet  fever  and  acute 
malarial  infection  were  noted  as  having  occurred  in  a  number  of  cases 
just  before  the  onset  of  the  disease.  He  adds  that  this  coincidence 
has  been  observed  by  too  many  different  authors  to  be  merely  acci- 
dental. In  our  series,  cases  of  acute  illness  preceding  the  onset  of 
acute  poliomyelitis  by  a  month  or  less  occurred  as  follows : 


OHIO    STATE    BOARD    OF    HEALTH.  13 

Measles •  4 

Tonsillitis     1 

Whooping  Cough  ,1 

Acute  Rheumatism  . . .  : 1 

Pneumonia    1 

"Indigestion" 1 

Headache   and   Backache 1 

"Kidney  Trouble"   1 

This  list  is  as  complete  as  it  was  possible  to  procure,  but  does 
not  indicate  any  connection  between  these  diseases  and  acute  poliomye- 
litis. Epidemic  meningitis  and  acute  poliomyelitis  possess  many 
features  in  common.  A  number  of  sporadic  cases  of  the  former 
occurred  in  Cincinnati  and  Cleveland  during  the  outbreaks  of  acute 
poliomyelitis,  but  there  was  no  unusual  prevalence.  In  Dayton,  how- 
ever, in  1912,  outbreaks  of  these  two  diseases  occurred  simultaneously 
as  follows: 

Epidemic 

Meningitis        Poliomyelitis 
Month.  Deaths.  Cases. 

July 9  9 

August    17  8 

It  must  be  borne  in  mind,  however,  that  these  diseases  are  very 
much  alike,  and  that  one  may  easily  be  mistaken  for  the  other.  Mis- 
takes of  this  kind  were  discovered  during  the  course  of  an  investiga- 
tion in  Dayton.  There  was  a  tendency  to  record  the  so-called  fulmi- 
nating cases  of  acute  poliomyelitis  as  epidemic  meningitis.  The  fact 
remains,  however,  that  during  the  months  the  incidence  of  acute 
poliomyelitis  was  at  its  height,  the  number  of  cases  of  epidemic  menm- 
gitis  was  also  much  greater  than  usual,  as  bacteriological  investigation 
carried  on  in  a  limited  number  of  cases  showed. 

NATIONALITY. 

The  patients  were  all  American  born.  Many  of  the  parents,  on 
the  contrary,  came  years  ago  or  recently,  from  Europe.  A  study  of 
the  nationality  of  the  parents  is  of  some  importance  in  attempting 
to  secure  an  idea  of  the  influence  of  the  Scandinavian  and  Swedish 
epidemics  upon  the  incidence  of  the  disease  in  America.  One  patient 
was  found  who  had  had  the  disease  in  Europe  before  coming  to  this 
country,  but  is  not  included  in  our  series. 

It  is  not  necessary  to  go  into  details  of  the  nationality  of  the 
parents,  as  no  relation  to  an  European  focus  is  evident. 


14  MONTHLY    BULLETIN 

OCCUPATTOX    OF    PARENTS. 

Farmer , 31 

Mechanic 17 

Laborer 16 

Alerchant     6 

Carpenter 7 

Commercial  traveler,  locomotive  engineer,  manager 3  each. 

Janitor,   school   teacher,   mail   carrier,    clerk,   paper   hanger, 

fruit  peddler    2  each. 

Butcher,  driver,  plumber,  fireman,  druggist,  contractor, 
bookkeeper,  restaurant  keeper,  saloon  keeper,  waiter, 
postmaster,  shoemaker,  draughtsman,  conductor,  chauf- 
feur, baker  and  cook 1  each. 

This  table  indicates  to  some  extent  the  social  status  of  the  families 
in  which  the  cases  occurred. 

GENERAL   SANITARY    CONDITIONS. 

A  survey  of  the  sanitary  conditions  in  and  around  homes  where 
the  disease  occurred  was  made  with  a  view  to  determine  the  possibility 
of  a  relationship  between  insanitary  conditions  and  the  incidence  of 
acute  poliomyelitis.  It  has  been  stated  that  no  such  relationship  exists, 
and  that  the  most  ideal  domestic  environment  does  not  shield  from 
infection ;  \yhile  insanitary  conditions  and  improper  environment  do 
not  predispose  to  the  disease. 

The  general  sanitary  conditions  in  our  cases  were  recorded  as 
follows : 

Excellent.  Good.  Fair.  Bad.  Very  Bad. 

17  51  54  17  2 

From  this  table  it  appears  that  the  sanitary  conditions  were  at 
least  as  good  as  the  average  of  the  middle  classes  in  one  hundred  and 
twenty-two  of  the  cases.  The  families  in  Avhich  cases  occurred  were 
recorded  according  to  their  circumstances  as  follows : 

JFell  to  do  Moderate.  Poor. 

13  100  la 

This  again  demonstrates  that  the  so-called  middle  classes,  or 
families  in  moderate  circumstances,  suffer  the  most.  Of  course  this 
class  comprises  a  large  majority  of  the  population. 

PRESENCE  OF   ANIMALS   AND   FOWLS. 

Some  years  ago  coincident  paralysis  among  animals  and  children 
with  acute  poliomyelitis  was  noted  and  commented  upon.  Paralysis 
among  chickens  was  most  frequently  met  with.    This  has  been  studied 


OHIO    STATE    BOARD    OF    HEALTH.  15 

and  ascribed  to  a  peripheral  neuritis  rather  than  to  a  lesion  of  the 
central  nervous  system.  Flexner  (i6)  was  able  to  set  up  a  disease 
in  chickens  resembling  acute  poliomyelitis  by  feeding  them  prior  to 
inoculation  with  an  unusual  and  improper  food.  Horses  and  cattle 
have  also  been  found  paralyzed  in  the  presence  of  an  outbreak  or 
acute  poliomyelitis,  but  in  the  cases  investigated  no  lesions  similar  to 
those  found  in  the  human  spinal  cord  have  been  described.  Many 
interesting  histories  of  coincident  paralysis  in  human  beings  and  the 
lower  animals  have  been  related  and  recorded.  Investigation  gen- 
erally reveals  a  lack  of  scientific  proof. 

With  the  exception  of  monkeys,  young  rabbits  and  chickens  (?), 
it  has  not  been  found  possible  to  set  up  acute  poliomyelitis  in  the 
lower  animals  by  any  known  method.  Further  investigation  along  this 
line  is  needed.  Most  exhaustive  work  has  been  recorded  by  the 
Massachusetts  State  Board  of  Health  (17),  to  whose  report  the 
reader  is  referred  for  further  information. 

In  our  cases  the  presence  of  animals  was  recorded  as  follows : 

Horses  and  Cows 


Farm  Animals. 
.  40 

Horses  Only. 

7 

Only. 

1 

Chickens  Only. 
25 

Horses  and 

Chickens. 

5 

Cows  and 

Chickens. 

1 

Cow  and  Chickens. 

1 

Dog  and 

Chickens 

2 

Chickens  and  Cats. 
1 

Sickness  or  paralysis  among  such  animals  was  also  investigated 
and  recorded. 

Paralyzed  horse    1      Rabies  in  dogs 1 

Paralyzed  hog  1      Rabbits  dead  1 

Chickens   dead 1      Hog  cholera    1 

Sick  cat  1 

These  cases  of  sickness  occurred  within  the  month  preceding  the 
onset  of  acute  poliomyelitis.  No  special  information  of  value  is  de- 
rived from  this  table. 

SEWAGE    DISPOSAL. 

As  bearing  on  the  domestic  environment,  the  methods  of  sewage 
disposal  were  investigated  and  are  here  recorded. 

Flush  Closets.        Privy  Vaults  Cesspools. 

26  103  2 


It)  MONTHLY    BULLETIN 

CONTACT. 

The  question  of  contact  and  its  influence  upon  the  dissemination 
of  the  disease  is  one  of  the  most  difificult  lines  of  inquiry.  One  has  to 
become  familiar  with  the  neighborhood  and  its  habits  to  appreciate 
this  factor  at  its  true  value.  In  some  neighborhoods  children  mingle 
freely  and  contact  is  usual,  while  in  others  the  children  are  restricted 
and  contact  seldom  occurs.  There  are  several  varieties  of  contact, — 
that  of  a  healthy  virus  carrier  with  other  children,  children  sick  of  the 
typical  disease  with  healthy  children ;  children  sick  with  abortive  cases 
of  the  disease  with  healthy  children ;  and  the  contact  of  so-called 
"missed"  cases  with  susceptible  individuals.  In  investigating  out- 
breaks of  typhoid  fever  contact  has  been  found  to  be  responsible  for 
infection  in  neighborhoods  where  children  mingle  freely.  The  char- 
acter of  the  neighborhood  and  social  status  of  the  individuals  compos- 
ing it  have  a  considerable  influence  upon  the  importance  of  contact 
as  a  factor  in  the  spread  of  acute  poliomyelitis.  Owing  to  the  nature 
of  this  investigation,  even  in  those  cases  personally  studied,  it  is  not 
thought  that  a  proper  appreciation  of  the  sources  of  contact  has  been 
possible.  The  maximum  or  height  of  these  outbreaks  had  been  reached 
or  passed  before  the  investigation  was  made;  and  for  this  reason  it  is 
probable  that  a  number  of  abortive  cases  have  been  missed.  Having  in 
mind  these*  disadvantages,  the  fact  that  in  eighteen  instances  per- 
sonal contact  with  a  paralyzed  patient  was  traced,  and  that  contact  with 
an  abortive  case  was  detected  in  four  instances,  is  significant.  Cases 
occurring  synchronously,  or  within  the  lapse  of  less  than  two  days, 
are  not  included  in  this  number.  In  ninety-two  cases  there  were 
other  patients  suffering  from  the  same  disease  in  the  immediate  vicin- 
ity, and  personal  contact  was  possible  or  probable.  Only  twenty-two 
of  the  cases  were  truly  sporadic.  In  Dayton  there  was  one  marked 
neighborhood  outbreak,  in  which  five  cases  occurred,  one  fol- 
lowing the  other  at  an  interval  of  not  less  than  four  days.  The  chil- 
dren in  this  part  of  the  city  mingle  freely  and  play  together  on  the 
streets.  Even  infants  in  arms  are  taken  to  the  motion  picture  shows, 
and  it  appears  logical  to  presume  that  these  gatherings  afford  an  ideal 
situation  for  the  transmission  of  infection,  with  their  stuffy,  ill-venti- 
lated atmosphere  and  the  closely-crowded  seats.  During  one  day  of 
investigation  the  parents  of  twelve  patients  were  asked  whether  they 
took  their  families  to  these  places,  and  eleven  gave  positive  answers. 
Many  from  different  parts  of  the  city  frequented  the  same  hall. 

Twenty-one  of  the  patients  whose  cases  were  studied  at- 
tended school  prior  to  the  onset  of  acute  poliomyelitis,  and  all  those 
whose  deformities  did  not  prevent,  returned  as  soon  as  the  acute  symp- 


OHIO    STATE    BOARD   OF    HEALTH. 


]7 


toms  had  subsided.  One  hundred  and  twenty-two  brothers  and  sisters 
of  cases  attended  school.  In  this  investigation  no  single  school  was 
found  to  be  a  focus  of  infection. 


AGE. 

Under 

Two  Years. 

Months 
6 

No. 

Cases. 
1 
1 
2 
1 
2 

Months 
12    

No. 

Cases. 
1 

1 
1 
2 
3 

Months 

17   

18   

19   

20  ..... 

00 

No. 

Cases. 
2 

7   

13  .... 

14  .... 

15   

5 

8   

9  

1 
8 

10 

16   .... 

- 

2 

- 

Total   . 

7 

8 

13 

BY 

YEARS. 

Age. 

0 

No. 

Cases. 

18 

22 

23 

12 

10 

Age. 
7   

No. 

Cases. 
5 
5 
1 
1 
2 

Age. 

16   

17   

24   

25   

36    

No. 

Cases. 
1 

3   

4   

5   

6   

9   

10   

11   

14  

2 
1 
1 

2 

BY  FIVE-YEAR  PERIODS. 

98  or  77%  were  five  and  vinder. 
18  or  14%  were  ten  and  undpr. 

3  or  2.3%  were  fifteen  and  under. 

3  or  2.3%  were  twenty  and  under. 

Eighty-five  per  cent,  of  the  cases  were  not  over  six  years  of  age. 
Over  twenty-eight  per  cent,  of  the  cases  were  between  the  ages  of 
two  and  three.  Practically  all  observers  have  found  that  the  large 
majority  of  cases  occur  during  the  first  five  years  of  life.  After 
forty  years  of  age  the  disease  is  practically  unknown.  The  earliest 
case  on  record  occurred  in  a  child  twelve  days  old,  described  by 
Duchenne  (i8).  The  youngest  patient  in  our  series  was  six  months, 
and  the  oldest  thirty-six  years  of  age. 


EXPERIMENTS    ON    THE   TRANSMISSION    OF   ACUTE    POLIOMYE- 
LITIS  BY  STOMOXYS   CALCITRANS  AND   OTHER  BLOOD- 
SUCKING ARTHROPODA. 

Owing  to  the  fact  that  acute  poliomyelitis  had  been  quite  preva- 
lent in  Ohio  for  the  last  few  years,  it  seemed  advisable  in  October  1912, 
for  the  staff  of  the  State  Board  of  Health  to  determine,  if  possible, 
something  definite  in  regard  to  the  disease,  and  to  find  out  whether 
acute  poliomyelitis  could  be  transmitted  by  means  of  the  bites  of  blood- 


18  MONTHLY    BULLETIN 

sucking  insects.  The  report  of  Rosenau  and  Brues  in  September,. 
19 1 2,  that  they  had  accompHshed  this  by  means  of  the  biting  stable  fly, 
Stomoxys  calcitrmis,  followed  by  the  rather  rapid  confirmatory  work 
of  Anderson  and  Frost,  in  October,  1912,  made  it  desirable  to  ascer- 
tain further  details  in  connection  with  this  species,  and  also  to  inves- 
tigate other  blood-sucking  Arthropoda  which  might  throw  additional 
light  on  the  subject.  The  experiments  reported  are  not  entirely  con- 
clusive, but  are  the  results  obtained  in  a  number  of  experiments  with 
flies  which  it  was  possible  to  secure  in  the  fall  and  winter  of  1912  and 
the  spring  of  1913. 

In  the  experiments  of  Rosenau  and  Brues  some  300  flies  were 
used,  but  the  methods  reported  render  it  impossible  to  determine  with 
any  degree  of  certainty  how  many  of  this  number  fed  on  the  sick  ani- 
mals, or  later  on  the  healthy  ones,  or  to  know  how  long  such  flies 
lived  after  the  first  feeding.  In  their  report  they  state, — 'Tn  these 
experiments  it  is  important  we  think  to  use  proper  technic  in  order  to 
obtain  sucessful  results.  The  flies  should  be  handled  as  little  as  pos- 
sible. It  is  better  to  handle  the  monkeys  and  leave  the  flies  alone." 
The  reason  for  this  statement  is  not  at  all  clear.  The  previous  and 
rather  extensive  experience  of  one  of  us  (C.  K.  B.),  along  these 
lines  has  never  demonstrated  that  Stomoxys  is  easily  injured.  They 
will  always  feed,  if  hungry,  as  soon  as  opportunity  arises.  It  was 
very  desirable  to  know,  if  possible,  how  many  flies  fed  on  each  ani- 
mal, and  how  long  a  period  elapsed  from  the  time  they  fed  on  the  sick 
animal  until  the  next  feeding  on  a  healthy  monkey,  so  the  methods 
employed  are  given  in  detail. 

Flies  were  captured  in  numbers  and  liberated  in  one  of  the  large 
especially  built  breeding  cages.  A  layer  of  fresh  horse-dung  free 
from  fly  larvae  covered  the  bottoms  of  these  cages  and  was  frequently 
moistened.  The  construction  of  the  cages  is  well  illustrated  in  the 
accompanying  cut. 

They  measure :  base  4  feet  square,  height  3  feet,  sliding  door  2 
feet  wide  and  2  feet  6  inches  high.  Two  sections  on  each  side,  and 
two  on  top  are  covered  with  number  16  screen.  The  bottom  of  the 
cage  consists  of  a  zinc  tray,  6  inches  deep.  The  middle  board  of  the 
top  contains  two  circular  holes,  two  and  a  half  inches  in  diameter, 
which  are  closed  by  sliding  zinc  plates. 

When  it  is  necessary  to  remove  flies  from  these  cages  a  lamp 
chimney,  the  top  of  which  is  covered  with  fly  screening,  is  placed  over 
one  of  these  holes,  and  the  cage  is  darkened  by  covering  the  screened 
parts.     After  a  time  the  flies  will  collect  in  the  light  chimney.     We 


OHIO    STATE    BOARD   OF    HEALTH.  19 

are  now  convinced  that  the  holes  should  be  placed  at  the  side  rather 
than  at  the  top  of  the  cage,  and  some  support  should  be  arranged  to 
hold  the  chimney  in  this  position,  as  flies  have  some  difficulty  in 
securing  a  footing  on  a  vertical  glass  surface. 

Lamp  chimneys,  such  as  those  shown  in  the  illustration,  were 
found  to  serve  admirably  for  feeding.  Both  ends  were  covered  with 
fine  cloth  fly-screening,  through  which  Stomoxys  will  feed  quite 
readily.  Not  more  than  ten  flies  should  be  used  in  a  single  chimney, 
as  all  specimens  are  not  equally  ready  to  feed  at  the  same  time,  and 
those  which  are  not  feeding  are  apt  to  disturb  the  others.  White 
screening  was  found  to  serve  best  for  this  purpose  because  of  the 
facility  with  which  the  action  of  the  proboscis  could  be  observed,  and 
a  check  kept  on  the  individuals  which  fed. 

The  experiments  were  performed  on  monkeys,  Macacus  rhesus 
being  used  exclusively.  Each  animal  was  placed  in  a  separate  cage 
and  the  inoculated  monkeys  kept  entirely  apart  from  all  others.  For 
facility  in  handling  the  animals,  a  collar  and  chain  was  put  on  each 
monkey,  and  the  end  of  the  chain  fastened  on  the  outside  of  the  cage. 
\A'hen  an  animal  w^as  required  for  feeding  or  taking  temperature,  the 
chain  was  pulled  out  far  enough  to  allow  the  end  to  be  passed  through 
one  of  the  boxes  used  for  this  purpose,  and  through  a  hole  at  the 
closed  end.  The  cage  door  was  then  opened  and  the  monkey  pulled 
into  the  box.  By  this  method  the  animal's  head  was  out  of  the  way 
while  the  style  of  box  allowed  perfect  freedom  for  feeding  purposes. 
At  first,  feedings  were  performed  on  one  flank  which  was  previously 
shaved,  but  this  part  was  later  discarded  for  the  abdomen,  which  is 
softer  and  quite  accessible  when  the  animal  is  placed  on  its  back  after 
being  pulled  in  the  box.  The  animals  soon  became  accustomed  to  the 
boxes  and  would  leap  in  after  the  cage  door  was  opened.  Separate 
boxes  were  used  for  the  sick  and  for  the  healthy  animals.  Holes  were 
bored  in  the  closed  end  for  ventilation.  The  type  of  box  is  well 
illustrated  in  the  cut  and  needs  no  further  description. 

The  same  method  was  used  in  feeding  bed  bugs,  except  that  only 
the  lower  end  of  the  chimney  was  covered  with  screening,  and  fewer 
specimens  were  used  for  feeding.  After  feeding,  the  bed  bugs  were 
emptied  into  separate  bottles,  those  which  were  well  engorged  being 
separated  from  those  of  which  there  was  some  doubt.  It  was  found 
that  they  would  feed  readily  in  daylight  if  hungry,  or  even  immedi- 
ately below  a  powerful  electric  light.  All  individuals,  however,  were 
not  equally  anxious  to  feed,  nor  did  they  all  consume  the  same  length 
of  time  in  feeding.  Some  would  feed  to  repletion  in  about  one  min- 
ute, while  others  took  from  five  to  seven  times  as  long. 


20  MONTHLY    BULLETIN 

Specimens  of  Argas  pcrsicns  (fowl  tick)  would  not  feed  in  this 
manner,  and  a  different  method  was  adopted,  the  monkey  being 
stretched  out  in  the  bottom  of  a  box  placed  over  water  and  the  ticks 
left  in  this  during  the  night.  It  was  found,  as  is  usual  with  this 
species,  that  all  did  not  feed,  and  only  those  which  showed  unmis- 
takable signs  of  having  done  so  were  kept  for  future  feeding  experi- 
ments. 

Experiments  were  commenced  in  October  with  a  monkey  whose 
previous  history  was  as  follows : 

Monkey  No.  i,  full  grown  male.     October  8th,  1912. 

Inoculated  with  virus  from  the  cord  of  M.  A.  W.,  male.  9  years 
of  age.  This  boy  showed-  symptoms  of  acute  illness  on  September 
2ist,  1912,  beginning  with  vomiting,  some  degree  of  temperature,  and 
a  stuporous  condition,  rapidly  passing  into  coma  on  September  22nd. 
Extensive  paralysis  appeared  on  this  date  and  death  occurred  from 
respiratory  failure  on  the  23rd  of  September,  forty-eight  hours  from 
the  onset.  On  September  24th,  a  necropsy  was  performed,  and  the 
spinal  cord  removed.  The  meninges  were  slightly  darker  than  usual ; 
the  gray  matter  of  the  cord  swelled  and  projected  beyond  the  cut 
margin  on  section;  minute  hemorrhages  were  distinguishable  in  the 
gray  matter  of  the  anterior  horns,  and  the  gray  and  white  matter  were 
much  soft-er  than  usual.  There  was  no  increase  of  spinal  fluid,  and 
no  change  in  its  character. 

Microscopically,  engorgement  of  the  blood  vessels  was  observed, 
with  marked  perivascular  infiltration  along  their  course ;  hemorrhages, 
and  beginning  degeneration  of  the  ganglion  cells  of  the  anterior  horns^ 
were  the  characteristic  changes,  and  the  presence  of  neurophages  in 
the  ganglion  cells  was  also  noted. 

Some  of  this  spinal  cord  was  removed  aseptically  and  placed  in 
50  per  cent,  glycerine,  previously  sterilized.  Five-tenths  of  i  c.  c.  of 
a  5  per  cent,  suspension  in  a  normal  salt  solution  was  inoculated  into 
the  monkey  sub-durally  under  strict  asepsis.  The  monkey  recovered 
as  usual  from  the  immediate  effects  of  the  operation,  and  no  rise  of 
temperature  was  noted  until  October  15,  1912. 

October  15,  1912.  Temperature  A.  M.  104.2,  coat,  ruffled, 
nervous. 

October  16,  1912.     Temperature  A.  M.   106.6,  weaker. 

October  17,  1912.  Temperature  A.  M.  104.6,  marked  weakness 
on  right  side. 

October  18,   1912.     Lying  at  bottom  of  cage,  very  weak. 

October  19,  1912.  Paralysis  of  right  side  almost  complete,  dull, 
hypersensitive  to  noise. 


OHIO    STATE    BOARD    OF    HEALTH.  21 

October  20,  1912.  About  the  same  as  on  19th.  When  taken 
from  cage  he  had  a  convulsion  and  appeared  to  cease  .breathing  for 
a  moment.  Animal  lies  with  eyes  closed  and  is  quite  still  except  when 
aroused. 

The  first  two  series  of  experiments  were  planned  to  follow  as 
faithfully  as  possible  the  natural  conditions  under  which  the  insect, 
Stomoxys  calcitrans,  feeds  in  nature.  It  is  logical  to  suppose  that 
this  fly,  the  bite  of  which  is  quite  sharp  and  painful,  might  easily  be 
disturbed  during  its  meal,  and  then  alight  and  finish  feeding  on  a 
different  animal.  On  the  other  hand  it  might  feed  to  repletion  on  the 
sick  animal  and  then  feed  on  a  healthy  one  at  the  next  normal  meal, 
which  might  be  on  the  same,  or  on  the  next  day. 

To  fulfil  the  first  of  these  requirements  for  experimental  purposes 
monkeys  Nos.  3  and  5  were  used.  In  these  cases  monkey  No.  i,  the 
sick  monkey,  and  either  No.  3  or  No.  5,  were  placed  in  their  separate 
boxes  on  the  table  together,  and  the  flies  allowed  to  feed  partly  on 
No.  I,  and  then  on  the  healthy  monkey.  They  were  passed  back  and 
forth  several  times  during  the  one  meal,  but  only  those-  bites  were 
counted  which  were  plainly  observed  on  the  two  animals  in  the  same 
transfer.  These  flies  were  not  used  again  for  feeding  experiments, 
as  misinterpretations  might  have  arisen  if  a  part  of  a  cycle  was  passed 
in  the  body  of  the  fly. 

To  meet  the  second  case  mentioned  above,  monkey  No.  6  was 
used,  only  one  monkey  being  used  for  this  experiment  because  of  the 
scarcity  of  flies  at  the  time.  In  this  experiment  the  flies  were  allowed 
to  feed  to  repletion  on  the  sick  monkey.  No.  i,  on  the  morning  of  one 
day,  and  then  fed  on  No.  6,  the  next  morning.  Fresh  flies  were 
secured  every  day,  so  that  a  few,  at  least,  could  be  fed  on  this  animal 
every  morning.  It  was  found  that  Stomoxys  calcitrans  would  feed 
more  readily  in  the  morning  th^n  later  in  the  day.  The  temperature 
charts  of  these  three  monkeys  follow. 

It  should  be  mentioned  that  controls  were  kept  with  the  experi- 
ment animals  in  all  cases. 

MONKEY  NO.  3. 

Young  Adult,  Female. 

Stomoxys   calcitrans  bites   from  No.  1. 


Date. 

Remarks. 

Temperature. 

1912. 

Oct.  21. 

Transfer   bites     3 

102.0 

22. 

Transfer  bites  20 

102.0 

23. 

Transfer  bites   15 

102.2 

24. 

Transfer  bites   18 

102.3 

22  MONTHLY    BULLETIN 

25.  Transfer  bites   U 103.0 

26.  Transfer  bites   14 102.6 

27.  Transfer  bites  21 103.2 

28.  Transfer  bites   16 102.2 

29.  Transfer  bites   14 103.0        102.2 

30.  Transfer  bites     7 104.0        103.2 

Restless,  not  eating  well. 

31.  Transfer  bites   18 102.8        102.4 

Nov.    1.     Transfer   bites     6 103.2        103.0 

2.  Transfer  bites  none 103.8        101.2 

3.  Transfer  bites     8 103.6        103.6 

4.  Transfer  bites     8 102.2        102.8 

5.  Stopped  feeding  103.8        102.6 

6 103.4        103.4 

7 lOa.6        102.8 

8 103.6        102.2 

9 103.4        108.4 

10 103. S        102.2 

11 102.2        102.6 

12 103.2        102.2 

1.3 101.8        100.2 

14.     ....• 102.4        102.2 

15 102.2        102.6 

16 102.4        102.2 

17 102.2        101.8 

Released,  but  kept  under  observation  until  December  14th.  1912. 

Inoculated  with  virus  Boudreau,  ex  No.  9,  on  this  date,  i  c.  c. 
subdurally  and  2  c.  c.  intraperitoneally,  which  in  normal  time  pro- 
duced a  typical  attack  of  acute  poliomyelitis.  The  changes  found  post- 
mortem were  characteristic. 

MONKEY  NO.  5. 

Three  Fourths  Grown  Male. 

Stomoxys  calcitrans  bites   from  No.   1. 

Date.  Remarks.  Temperature. 

1912. 

Oct.  23.     Transfer   bites   13 102.0 

24.  Transfer  bites   16 103.0 

25.  Transfer  bites  29 102.4 

26.  Transfer  bites  18 102.0 

27.  Transfer  bites   19 102.2 

28.  Transfer  bites   19 102.4 

29.  Transfer  bites  20 102.2        102.0 

30.  Transfer  bites   14 101.8        103.0 

31.  Transfer  bites   15 102.8        101.8 

Nov.    1.     Transfer  bites     5 102.0        102.0 

2.     Transfer  bites     4 102.2        102.0 


OHIO    STATE    BOARD   OF    HEALTH.  23 

3.  Transfer  bites     7 102.6        102.6 

4.  Transfer  bites     6 102.4        101.6 

5.  Stopped  feeding 103 . 2         103 . 2 

6.  Coat  ruffled,  will  not  eat 104.4 

7 103.4        104.8 

8.  Eats  well  again 103.4        104.2 

9,     103.2        103.6 

10 102.6        102.0 

11 100.8        102.2 

12 102.2        102.6 

13 102.2        102.2 

14 102.0        102.0 

15 ; 101.6        102.4 

16 101.8        102.0 

17 101.8        102.2 

Released,  but  kept  under  observation  until  December  14th,  1912. 

Inoculated  with  virus  Boudreau,  ex  No.  9,  on  this  date,  i  c.  c. 
subdurally  and  2  c.  c.  intraperitoneally,  which  in  normal  time  pro- 
duced a  typical  attack  of  acute  poliomyelitis,  and  changes  found  post- 
mortem were  characteristic. 

MONKEY  NO.  6. 

Half  Grown  Male. 

Stomoxys  calcitrans  bites   from  No.   1. 

Date.  Remarks.  Temperature. 

1912. 

Oct.  25.      8   flies    fed 102.6 

26.  5  flies   fed 102.2 

27.  3  flies   fed 102.0 

28.  6  flies   fed 102.2 

29.  12  flies   fed 102.0        102.0 

30 101.8        103.0 

31.   8  flies  fed 102.4   102.4 

Nov.  1 102.8    101.4 

2.      9  flies  fed 102.6        102.9 

3 102.4        102.4 

4.      8  flies   fed 102.8        102.6 

5 102.6        102.4 

6.  5  flies  fed 102.0        102.0 

7.  Stopped  feeding,  for  lack  of  flies 102.0        102.0 

8 102.6        102.4 

9 102.0        102.0 

10 101.8        101.8 

11 101.0        102.0 

12 102.2        102.6 


24  MONTHLY    BULLETIN 

Temperature  was  taken  daily,  but  remained  normal  until : 

Nov.  26,  when  animal  was  inoculated  with  virus  Flexner,  f  c.  c.  sub-durally, 
and  3  c.  c.  intraperitoneally.  Recovered  from  the  operation  without  complica- 
tions. 

Date.  Remarks.  Temperature. 

Nov.  27 : 102.6        103.8 

28 103 . 0  not  tak'n 

29.  Irritable,  not  eating  well 105 . 6 

30.  Coat  ruffled  104.4        105.2 

Dec.     1.     General  incoordination    104.2        104.4 

Right  arm  weak, 

2.     Paralysis  complete  101.4        103.0 

3 98.0 

4-12.     Paralysis  complete,  but  eats  well. 
12.    Killed. 
P.  M.     Showed  lesions  typical  of  acute  poliomyelitis. 

It  will  be  noticed  that  there  were  182  direct  transfer  bites  on 
No.  3,  and  185  on  No.  5.  In  both  cases  there  was  a  period  of  rest- 
lessness, and  of  heightened  temperature,  accompanied  by  a  loss  of 
appetite  and  a  ruffled  condition  of  the  coat.  The  significance  of  these 
symptoms  is  doubtful  when  one  realizes  that  both  animals  were  inocu- 
lated with  virus  Boudreau  on  December  14th,  and  both  came  down 
with  typical  cases  of  acute  poliomyelitis.  Whatever  was  the  signifi- 
cance of  the  first  rise  of  temperature,  no  immunity  was  conferred 
against  later  infection. 

In  the  case  of  No.  6,  in  which  a  day  elapsed  between  the  feedings 
on  the  sick  and  healthy  animals,  64  flies  were  fed  on  both  monkeys. 
There  was  no  rise  of  temperature,  and  no  signs  of  sickness  of  any 
kind,  and  this  animal  too  came  down  with  a  typical  attack  of  the 
disease  a  month  later  when  inoculated  with  virus  Flexner. 

It  was  found  to  be  impossible  to  breed  Stomoxys  calcitrans 
through  the  winter,  but  on  November  ist  a  number  of  larvae  in  dif- 
ferent stages  were  collected  by  Professor  J.  S.  Hine  and  one  of  us 
(C.  K.  B.)  and  placed  in  one  of  the  large  cages,  together  with  some 
perfectly  fresh  horse  dung.  Adult  flies  began  to  emerge  on  December 
4th,  so  monkey  No.  15  was  inoculated  on  December  6th  to  take  ad- 
vantage of  these  if  sufficient  emerged.  The  history  of  this  monkey 
after  inoculation  is  as  follows: 


OHIO    STATE   BOARD   OF    HEALTH.  25 

MONKEY  NO.  15. 

HALF  GROWN  MALE. 

Inoculated  with  virus  Boudreau  ex  No.  9,  i  c.  c.  of  a  5  per  cent. 
suspension  in  normal  salt  solution,  subdurally  and  5  c.  c.  intraperi- 
toneally  on  December  6th,  1912. 

Recovered  from  the  operation  as  usual. 

Date.  Remarks.  Temperature. 

1912. 

Dec.    7.  Normal  102.6 

8.  Normal   : 102.2 

9.  Not  eating  well ' 102.6        103.8 

10.  Inactive  102.2  103.0 

11.  Not  using  right  arm 103.2  104.6 

12.  Hypersensitive  104.4  104.6 

13.  Paralysis  complete    100.4  95.6 

14.  Scarcely  breathing    94  .,0 

Killed. 

P.  M.  showed  lesions  typical  of  acute  poliomyelitis. 

Feeding  was  commenced  on  this  monkey  two  days  after  inocu- 
lation, December  8th,  two  other  monkeys,  Nos.  13  and  16,  being  used 
in  this  experiment. 

It  was  decided  to  vary  the  conditions  of  feeding  so  as  to  more 
nearly  approach  the  conditions  in  the  Rosenau  and  Brues,  and  Ander- 
son and  Frost  experiments.  This  was  done  by  using  the  flies  over 
and  ^ver  again  as  long  as  they  lived,  so  that  no  steps  were  taken  to 
be  sure  that  flies  which  had  bitten  one  or  both  monkeys  on  a  previous 
day  should  not  be  used  on  a  later  date.  Thus  a  few  of  the  flies  were 
fed  on  December  8th,  and  also  on  December  13th,  and  on  every  day 
between  these  dates.     The  histories  of  these  two  cases  follow : 

MONKEY  NO.  13. 

Three-fourths  Grown  Male. 

Stomoxys  calcitrans  bites  from  No.  15,   (and   17). 

Date.  Remarks.  Temperature. 
1912. 

Dec.     8.      8  transfer  bites ,102.8      • 

9.     10  transfer  bites 102.0        102.2 

10.  8  transfer  bites 102.0        101.0 

11.  12  transfer  bites 102.0        102.2 

12.  25  transfer  bites 101.6        102.4 

13.  25  transfer  bites 102.2        102.6 

14.  Stopped  feeding  102.0        101.8 

1,5 102.0  nottak'n 


2fi  MONTHLY    BULLETIN 

16 101.0  102.0 

17 101.6  102.6 

18 102.0  102.6 

19.  15  bites  from  17 102.4  102.4 

20.  6  bites  from  17 101.4        102.4 

Temperature  taken  until  January  nth,  1913,  but  remained  normal. 

MONKEY  NO.  16. 
Half  Grown  Male. 

Date.  Remarks.  Temperature. 

1912.  . 

Dec.     8.     12  transfer  bites 102.6 

9.     17  transfer  bites 102 . 0 

10.  11  transfer  bites 102.4 

11.  10  transfer  bites 101.8        102.6 

12.  27  transfer  bites 102.2        102.4 

13.  17  transfer  bites 103.0        103.0 

14.  Stopped  feeding  for  lack  of  flies 102.4        103.6 

15 102.4  nottak'n 

16 102.0        102.0 

17.     ..; 101.8        102.0 

18 102.2        102.0 

19 102.0        102.4 

20 101.8        102.0 

This  animal  was  kept  under  close  observation  until  February 
20th.  1913,  but  showed  no  signs  of  sickness  of  any  kind. 

Although  there  were  about  100  transfer  bites  on  each  monkey 
from  No.  15,  up  to  the  date  of  complete  paralysis,  no  sign  of  sickness 
was  observed  in  either  case. 

EXPERIMENTS    WITH    CIMEX    LECTULARIUS    LINN. 

Bed  bugs  were  collected  in  number  from  an  empty  teneinent 
house  and  as  these  had  apparently  not  been  fed  for  some  weeks,  they 
proved  to  be  very  suitable  for  feeding  experiments. 

At  first  about  50  of  them  were  fed,  on  monkey  No.  9,  in  the 
usual  method  of  feeding  Argas  persicus,  i.  e.,  enclosing  them  at  night 
with  the  animal,  but  this  method  was  discarded  for  Cimex  when  it 
was  found  that  they  would  feed  so  readily  in  daylight  or  under  an 
electric  light. 

The  advantages  of  this  direct  method  of  feeding  are  that  the 
insects  are  under  direct  observation  while  feeding,  a  few  can  be  fed 
at  a  time  and  direct  transfers  made,  time  is  saved,  the  difficulties  of 
collecting  the  bugs  from  the  box  are  obviated,  and  it  is,  moreover, 
less  trying  for  the  experiment  animals. 


OHIO  STATE  BOARD  OF  HEALTH.  27 

In  the  first  of  these  experiments  monkeys  Xos.  9  and  14  were 
used,  No.  14  being  bitten  by  35  bugs  four  days  after  they  had  last  fed 
on  the  sick  animal,  and  also  receiving  45  direct  transfer  bites  from 
No.  9. 

The  histories  of  these  two  cases  follow: 

MONKEY  NO.  9. 
Half  Grown  Male. 

November  26,  1912.  Inoculated  with  virus  Boudreau,  1  c.  c.  (Suspension) 
sub-durally  and  3  c.  c.  intraperitoneally.  Temperature  102.2.  Recovered  from 
operation  as  usual. 

Date.  Temperature,  a.  m.  and  Remarks. 

Nov.  27.  102.4,  animal  normal. 

2S.  102.0. 

29.  102.6. 

30.  103.0. 

Dec.     1.     104.0,  is  nervous,  does  not  eat  well. 

2.  104.4,  hypersensitive,  holds  head  erect  with  difficulty. 

3.  103.0,  paralysis  of  left  side  complete,  extremely  sensitive  to  noise. 

4.  102.8,  paralysis  complete  except  for  slight  power  in   right  arm. 
5  and  6.     Condition  the  same. 

6.     Dying.    Animal  killed. 
P.   M.     Showed  lesions   typical  of  the   acute   stage   of   acute  poliomyelitis. 

MONKEY  NO.  14. 
.">  Full  Grown  Female. 

Cimex  lectularius  bites  from  No.  9. 

Date.  Remarks.  Temperature. 

1912. 

Dec.     5.     1-5  transfer  bites 102.4 

6.     30  transfer  bites 102.0 

7 102.0 

8.     35  bugs  fed,  which  last  fed  on  Xo.  9  on  Dec.  4 102.4 

9 102.2        101.4 

10 102.0        102.6 

11 102.6        102.0 

12 102.2        101.2 

13 102.6        102.2 

14 102.0        101.6 

Temperature  taken  until  December  28th,  but  remained  normal. 

Animal  kept  under  observation  until  [March  12th,  191 3.  but  re- 
mained quite  healthy. 

It  will  be  observed  that  in  this  case  there  were  So  bites  from  the 
sick  to  the  healthy  animal,  of  which  number  45  were  direct  transfers. 
but  these  were  not  followed  bv  anv  signs  of  sickness. 


28 


MONTHLY    BULLETIN 


These  experiments  were  repeated  later  in  the  month,  using 
monkeys  Nos.  17  and  12  for  inoculation  and  transfer  bites  respec- 
tively. In  the  experiment  97  certain  transfer  bites  were  secured 
immediately  before  the  acute  stage  was  reached,  but  no  symptoms  of 
sickness  of  any  kind  became  evident  within  the  next  60  days,  during 
which  the  animal  was  under  constant  observation. 

The  histories  of  these  two  animals  during  the  experiment  are  as 
follows : 

.  MONKEY  NO.  17. 
Half  Grown  Male. 

December  14,  1912,  inoculated  with  virus  Boudreau,  Ex.  9,  as  control  to 
Nos.  3  and  5,  q.  v. 


Date. 
Dec.  15. 
16. 
17. 
18. 
19. 
20. 
■  21. 
22. 
23. 
24. 


Remarks. 


HA'persensitive 


Head  drawn  to  right.... 
Hind  quarters  paralyzed. 

Back  bowed  

Very  weak  


Temperature,  p.m. 
102.2 
103.4 
101.8 
103.6 
102.8 
104.6 
104.4 
102.2 

98.2 

94.0 


Date. 
1912. 
Dec.  18 
19 
20, 
21 
22 
23 
24 
25 


MONKEY  NO.  12. 
Half  Grown  Female. 
Cimex  lectularius  bites  from  No.  17. 
Remarks. 


Tcuipcraiure. 


72  transfer  bites 101 

25   transfer  bites 102.0 


102.0 

102.4 

102.6 

103.0 

102.6 

102.8 

103.0 

102.6 

102.2 

102.2 

102.6 

102.2 

102.6 

102.4 

This  animal  was  kept  under  close  observation  and  the  tempera- 
ture taken  daily  until  March  12th,  191 3,  but  at  no  time  did  it  show 
signs  of  sickness  of  any  kind. 


EXPERIMENT   WITH   ARGAS   PERSICUS    (oKEN). 

A   considerable   number   of   specimens   of   the    fowl   tick,   Argas 
persicfi^    (Oken),    were    received   earlier   in    the   year    from    Corpus 


OHIO    STATE    BOARD    OF    HEALTH.  29 

Christi,  Texas,  through  the  kindness  of  Dr.  W.  D.  Hunter.  These 
were  kept  until  December  3rd,  when  about  100  were  fed  on  monkey 
No.  9  on  the  night  of  that  date.  It  was  intended  to  keep  these  for  a 
few  weeks  and  then  to  feed  them  again  on  healthy  monkeys.  Un- 
fortunately for  this  scheme,  however,  complications  which  had  been 
suspected,  but  not  quite  expected,  arose. 

Mr.  C.  P.  Lounsbury,  Chief  of  the  Division  of  Entomology  for 
the  Union  of  South  Africa,  working  on  this  species  in  1903,  saw  an 
adult  tick  turn  black  and  die  soon  after  feeding  on  him,  and  Donitz 
(1907,  p.  28)  saw  larvae  which  had  fed  on  white  mice  die  rapidly 
after  feeding.  He  supposed  that  his  larvae  died  owing  to  the  blood 
of  the  mice  being  toxic  for  the  ticks,  but  he  brought  no  proof  to 
support  the  hypothesis. 

Of  the  100  ticks  which  fed  on  monkey  No.  9  on  December  3rd, 
34  were  dead  within  the  first  week,  and  by  February  20th,  1913,  only 
6  were  up  ready  to  feed,  and  even  these  were  much  thicker  and 
blacker  than  normal.  Those  which  died  were  a  reddish  black  color, 
with  blood  colored  margins,  and  were  quite  as  thick  through  as  newly 
engorged  ticks. 

It  appeared  to  be  cjuite  impossible  for  them  to  digest  the  blood 
of  monkeys,  and  it  is  probable  that  they  must  rely  entirely  on  bird 
blood  for  food,  as  this  is  the  only  kind  they  can  digest.  From  the 
appearance  of  dead  specimens,  and  the  comparison  of  these  with 
tho^e  still  living  it  would  seem  that  those  ticks  which  were  most 
fully  engorged  were  the  first  to  die,  and  that  those  which  had  taken 
less  blood  lived  longer. 

STOMOXYS  CALCJTRANS  (Linn  1758). 

Plate  1. 

Common  name:  Stable  Fly. 

Stomoxys  calcitrans  is  now  widely  distributed  over  the  world, 
and.  as  is  also  the  case  with  the  house  fly,  its  original  home  is  not 
definitely  known.  The  main  factors  in  the  spread  of  both  species 
were  probably  the  same,  and  operated  at  the  same  time.  The  stable 
fly  is  not  so  common  about  houses,  however,  and  differs  from  Musca 
domestica  entirely  in  its  feeding  habits.  Its  occasional  occurrence  in 
dwellings  makes  it  desirable,  however,  to  give  a  few  particulars  which 
will  serve  to  distinguish  it  from  the  other  two  species  which  are 
known  as  "house  flies."  The  figure  numbers  in  the  following  descrip- 
tions refer  to  Plate  II. 


30  MONTHLY    BULLETIN 

Musca  Douicstica  Linn.     The  House  Fly. 

Egg:  About  i  m.  m.  long,  elongate,  cylindrical,  oval,  rather 
more  pointed  at  the  anterior  end,  dull  chalky-white  in  color.  About 
lOO  to  150  eggs  are  laid  in  a  mass  in  the  crevices  in  house  refuse  or 
in  accumulations  of  horse  manure.  Under  favorable  conditions  these 
hatch  in  from  8  to  24  hours. 

Larva:  7  to  10  m.  m.  long  when  full  grown,  greasy  white  in 
general  color,  except  for  the  darker  color  of  the  contents  of  the 
alimentary  tract.  This  larva  can  be  distinguished  from  others  by  the 
shape  and  size  of  the  plates,  which  surround  the  posterior  respiratory 
apertures.  These  are  situated  on  the  broad  end  of  the  body  and  are 
close  together,  comparatively  large,  and  circular  except  for  the  inside 
edges,  which  are  straight.  Under  favorable  conditions  the  larva  is 
full  grown  and  pupates  in  from  4  to  7  days.     (Fig.  2.) 

Pupa:  (Fig.  3.)  Yellowish  brown  to  dark  reddish  brown,  barrel 
shaped,  but  tapering  slightly  to  the  anterior  end.  Length  6  to  8  m.  m. 
Under  most  favorable  conditions  of  temperature  and  humidity  the 
pupal  stage  lasts  3  to  5  days. 

Adult:  (Fig.  i.)  The  normal  length  is  about  6  to  7  m.m.,  mouse 
gray  in  color,  while  the  thorax  has  four  black,  longitudinal  stripes, 
which  are  usually  most  sharply  defined  in  front.  It  may  be  noticed 
that  the  compound  eyes  more  nearly  meet  on  top  of  the  head  in  the 
male  than  in  the  female.  The  proboscis,  when  at  rest,  is  not  visible 
from  above.  The  end  of  the  4th  longitudinal  vein  bends  sharply  up 
so  as  to  nearly  join  the  vein  above  it.  A  few  females  hibernate  in 
winter.     This  species  cannot  bite,  and  does  not  suck  blood. 

Fannia  canicularis  Linn.    The  Lesser  House  Fly. 

Egg:  This  has  not  been  studied  by  the  writer  but  it  is  reported 
to  be  deposited  in  decaying  animal  and  vegetable  matter. 

Larva:  (Fig.  5.)  About  8  m.  m.  long  when  full  grown,  brownish 
in  color  and  somewhat  abruptly  narrowed  in  front.  This  larva  may~ 
readily  be  distinguished  from  that  of  Musca  domestica  or  of  Stomoxys 
calcitrans  by  the  presence  of  spines  such  as  are  shown  in  Fig.  5. 

Pupa:  (Fig.  6.)  The  bristles  of  the  last  larval  stage  persist  in 
the  pupal  stage,  as  does  also  the  brownish  coloration.  The  puparium- 
is  slightly  shorter  than  the  normal  extended  larva. 

Adult:  (Fig.  4.)  Normal  length  about  6  m.m.,  but  this  fly  is 
much  more  slender  than  the  common  house  fly.  The  thorax  is 
blackish  or  dull  gray,  and  the  longitudinal  stripes  are  not  noticeable 
in  the  male.     Front  of  the  head  shining  white  in  the  male,  while  that 


OHIO    STATE    BOARD    OF    HEALTH.  3t 

of  the  female  is  darkish  gray.  Width  of  the  vertex  in  the  male  is 
one-seventh,  in  the  female  one-third  the  total  width  of  the  head.  The 
proboscis  is  not  visible  from  above.  End  of  the  4th  longitudinal  vein 
not  bent  up  towards  the  vein  above,  but  parallel  to  it.  Like  the  house 
-fiv  this  species  cannot  bite,  and  does  not  suck  blood. 

Stonioxys  calcitrans  Linn.     The  Stable  Fly. 

Egg:  (Plate  III.  Fig.  I.)  About  i  m.  m.  long,  white,  elongate, 
and  banana-like  in  shape.  One  side  straight,  with  a  deep  groove,  the 
-other  curved.  Laid  in  small  masses  of  40  to  70,  in  accumulations 
of  moist  and  fermenting  vegetable  matter,  or  in  fresh  horse  manure. 
At  favorable  temperature  the  eggs  hatch  in  2  to  4  days. 

Larva:  (Fig.  8.)  Length  when  full  grown  about  10  m.  m.  long, 
very  similar  in  appearance  and  color  to  the  larva  of  Musca  domestica, 
but  may  be  readily  distinguished  from  it  by  the  plates  of  the  respira- 
tory tubes  which  are  distinctly  smaller,  circular,  and  from  4  to  6 
times  as  far  apart.  Larval  stage  usually  lasts  15  to  21  days,  but  may 
be  extended  under  unfavorable  conditions  up  to  80  days. 

Pupa:  (Fig.  9.)  Bright  reddish  brown  to  chestnut  brown  in 
color,  and  normally  6  m.  m.  long ;  precisely  similar  in  appearance  to 
that  of  the  house  fly,  from  which  it  may  be  distinguished  by  the  plates 
in  the  same  manner  as  the  larva.  In  summer  the  adults  usually 
emerge  in  9  to  13  days  after  pupation. 

^dult:  (Fig.  7.)  Normal  length  about  7  m.  m.,  rather  more 
robust  than  either  of  the  foregoing,  darkish  gray.  Thorax  with  four 
conspicuous  blackish  longitudinal  stripes.  Abdomen  dotted  with  clove 
brown.  \'ertex  one-fourth  in  the  male  and  one-third  in  the  female, 
the  width  of  the  head.  Proboscis  shining  black,  projecting  horizon- 
tally in  front  of  the  head,  and  visible  from  above  when  not  feeding. 
The  end  of  the  4th  longitudinal  vein  bent  up,  but  not  so  much  as  in 
the  house  fly.  A  biting  fly,  both  sexes  suck  blood  from  human  beings 
as  well  as  from  horses,  cattle,  etc.  Seen  in  houses  chiefly  on  dull,  cool 
davs.  which  accounts  for  the  old  saying  that  it  is  a  sign  of  rain  when 
the  flies  bite. 

Habitat:  Farmyards  and  stables  are  evidently  the  favorite 
haunts  of  this  fly.  It  occurs  also  in  fields  and  open  woodSj  especially 
where  cattle  or  horses  are  grazing.  It  is  evidently  by  no  means  un- 
common even  in  large  cities,  and  numbers  have  been  seen  in  quite  busy 
streets.  It  is  fond  of  resting  on  surfaces  fully  exposed  to  the  sun, 
such  as  doors,  gates,  and  rails,  and  to  a  less  extent  also  on  stone  walls. 
Painted   surfaces   seem  to  be   specially  attractive  to   it.      It's  flight  is 


82  MONTHLY    BULLETIN 

quite  inaudible  at  a  short  distance.  When  disturbed  it  frequently  re- 
turns to  the  same  spot,  as  though  it  were  a  favorite  resting  place.  It 
is  quite  active  during  the  warmer  part  of  the  day,  and  at  night  returns 
to  some  she'tered  spot  such  as  the  beams  in  a  shed.  In  Columbus  the 
numbers  of  this  species  dwindled  towards  the  end  of  October  in  1912. 
but  a  few  could  be  caught  up  to  the  end  of  November,  and  four 
specimens  were  taken  on  December  3rd.  In  captivity  these  flies  live 
but  a  short  time,  generally  less  than  a  week.  They  frequently  clean 
their  wings,  performing  their  cleaning  with  great  precision,  the  hind 
pair  of  legs  being  used  for  this  purpose.  The  lower  surface  is  combed, 
then  the  upper,  the  legs  are  then  rubbed  together  and  the  process 
repeated. 

Emergence  from  the  egg.  The  larva  makes  its  escape  from  the 
tgg  by  splitting  the  broad  end  of  the  groove.  leaving  it  slightly  raised, 
and  apparently  intact  on  the  opposite  side,  Plate  III.  Figure  i. 

The   Larva.      Plate   III,    Figs.    2   and   3. 

Color  creamy  white  to  yellowish,  shiny,  greasy  in  appearance. 
The  coiled  alimentary  tract,  when  filled  w^ith  food,  gives  the  posterior 
portion  a  dark  appearance.  The  longitudinal  tracheae  may  be  recog- 
nized as  two  submedian  white  lines  which  show  delicate  lateral 
branches,  The  posterior  stigmata  are  black,  while  the  thoracic  ones 
are  yellowish  in  color. 

In  form  the  larva  is  elongate,  tapering  towards  the  head  but 
broadly  rounded  behind.  The  segmentation  is  not  very  conspicuous, 
and  the  epidermis  is  bare,  not  having  hairs  nor  bristles.  On  the  head 
may  be  seen  two  large  divergent  mammiform  processes,  at  the  end  of 
which  are  the  minute  retractile  antennae,  which  are  apparently  each 
composed  of  four  sub-equal  segments.  The  mouth  parts  are  strongly 
chitinised  in  the  full  grown  larva  and  are  composed  of  a  number  of 
sclerites  as  shown  in  Figs.  2  and  3. 

The  last  seven  segments  are  furnished,  on  their  ventral  surface, 
with  raised  bands  of  tactile  tubercles.  The  posterior  stigmata  are 
two  in  number,  circular,  and  somewhat  distant  from  each  other.  The 
thoracic  stigmata  occupy  a  sub-lateral  position  on  the  third  segment, 
and  each  consists  of  five  circular  orifices,  (t.  s.).  These  are  connected 
with  a  large  bilateral  air  sac  which  extends  along  the  fourth  segment. 

Method  of  pupation:  The  time  taken  for  pupation  is  usually 
about  two  hours.  The  larva  at  first  becomes  quiet,  and  shortens 
rapidly,  chiefly  by  the  contraction  of  the  anterior  segments.  In  this 
way  it  assumes  a  form  which  resembles  a  barrel  in  shape.  At  this 
stage  it  is  still  yellowish  white  and  the  mouthparts  of  the  larva  are 
plainly  visible  through  the  soft  integument.     The  color  then  changes- 


OHIO    STATE    BOARD    OF    HEALTH.  83 

to  a  bright  yellow,  and  in  about  an  hour  longer  it  assumes  the  normal 
chestnut  color  of  the  puparium. 

The  puparium  is  from  5  to  6  m.m.  in  length,  only  eleven  segments 
are  visible,  the  anterior  one  bearing  the  minute,  bilateral,  thoracic 
stigmata,  while  the  broadly  rounded  posterior  segment  shows  the 
disc-like  posterior  stigmata.  Under  optimum  conditions  this  stage 
lasts  from  9  to  13  days. 

Development  of  the  adult:  About  three  days  before  the  emer- 
gence of  the  adult  fly,  the  cuticle  of  the  puparium  darkens,  and  event- 
ually splits  along  the  lateral  and  median  lines,  anteriorly,  and  trans- 
versely across  the  fourth  segment.  This  section  falls  away  and  the  fly 
escapes.  Prior  to  this  the  nymph  undergoes  its  final  ecdysis,  pushing 
its  effete  skin  off'  backwards  into  the  posterior  end  of  the  puparium. 
On  its  emergence  it  appears  as  a  small  dark  fly,  gray  in  color,  with 
thick  rudimentary  wings  of  a  dull  leaden  color.  Its  head  is,  at  this 
stage,  much  wider  than  the  thorax,  and  the  abdomen  is  attenuated. 
At  first  it  is  very  active,  the  period  of  activity  evidently  serving  to 
allow  the  fly  to  force  its  way  to  the  surface  before  the  wings  are  fully 
Erown  and  stiffened.  The  frontal  sac  is  constantly  inflated  during  this 
time,  and  no  doubt  serves  in  moving  fragments  of  earth,  etc.,  out  of 
the  way.  When  liberated  the  insect  spends  a  considerable  amount  of 
time  in  combing  out  the  hairs  on  the  arista  of  the  antennae. 

During  this  time  the  fly  constantly  changes  its  position,  and  the 
frontal  sac  is  contracted.  There  are  marked  changes,  too,  in  the  ab- 
domen and  wings.  The  abdomen  first  becomes  longer,'  and  is  con- 
stantly expanded  and  contracted,  and  gradually  assumes  its  normal 
coloring,  with  the  clove  spots.  The  wings  then  begin  to  expand,  a 
process  which  is  completed  in  less  than  five  minutes. 

The  fly  is  about  its  normal  size,  shape,  and  color  at  this  time,  but 
some  time  is  taken  in  the  final  hardening  of  the  integument,  and  in  the 
final  combing  operations,  which  seem  to  be  indispensable  before  flight. 
It  is  during  this  last  process  that  the  proboscis  is  at  last  raised  into  its 
horizontal  position. 

EXTERNAL    MOUTH    PARTS. 

The  figure  numbers  referred  to  in  this  section  apply  to  Plate  IV. 

Unlike  some  of  the  other  well  known  blood  sucking  Diptera  the 
male  of  this  species  also  feeds  on  blood,  and  I  have  been  unable  to 
determine  any  difference  between  the  mouth  parts  of  the  two  sexes  of 
Stomoxys  calcitrans.  The  following  description  will  therefore  apply 
equally  well  to  male  or  female. 
3    A.  p. 


34  MONTHLY    BULLETIN 

The  external  mouthparts  consist  of  maxillary  palpi  and  the  pro- 
boscis. (Fig.  I.  nixp,  and  pr.)  Maxillae  proper  and  mandibles  are 
not  found,  the  proboscis  consisting  of  the  labrum,  hypopharynx,  and 
the  labium. 

The  maxillary  palpi  consist  of  a  single  segment,  and  are  approxi- 
mately one-fourth  the  length  of  the  proboscis. 

The  proboscis,  in  a  resting  position,  extends  horizontally  below 
the  head,  and  may  be  plainly  seen  projecting  for  about  one-third  of 
its  length  in  front  of  the  head.  In  this  position  its  base  is  closely 
applied  to  the  lower  part  of  the  head,  in  the  ventral  groove,  but  when 
extended  it  wall  be  observed  that  its  attachment  to  the  lower  chitinous 
skeleton  is  membranous,  except  for  the  tw^o  strong  apodemes.  (ap. 
in  Figs.  I,  2,  and  4.)  The  maxillary  palpi  are  attached  to  this  mem- 
branous cone,  and  do  not,  in  any  part,  enclose  the  proboscis.  The 
proboscis  is  somewhat  longer  than  the  height  of  the  head,  distinctly 
thickened  in  the  basal  half,  black,  shining,  and  practically  smooth. 

The  labiitin,  or  lower  lip.  is  the  strong  black  part  referred  to,  and 
this  constitutes  the  sheath  for  the  labrum  and  hypopharynx.  The 
labium  consists  of  three  segments.  (Figs.  i.  i,  ii  and  iii.)  Segment  i. 
is  eight  .to  ten  times  the  length  of  the  other  two  together.  Segment  ii. 
is  very  small  and  inconspicuous,  and  segment  iii.  is  composed  of  the 
labella.  Throughout  the  whole  length  of  the  labium  is  the  dorsal 
groove,  in  which  lie  the  lal)rum  and  the  hypopharynx.  The  dorsal 
groove  is  deep  in  its  basal  part,  but  becomes  more  and  more  shallow 
distally.  Near  the  extreme  base  it  is  practically  closed  above  by  the 
overlapping  of  the  dorsal  margins  of  the  labium.     (Fig.  3.) 

The  outer  chitinous  walls  of  the  labium  are  comparatively  thin, 
but  very  hard,  while  the  interior  is  completely  filled  by  muscles  and 
tracheae.     (Fig.  3.) 

Segment  ii.  of  the  labium,  as  has  been  said,  is  very  small,  and 
appears  as  a  small  section  of  chitin  in  the  joint  between  i.  and  iii. 
Segment  iii.  is  composed  of  the  labella,  fitting  together  as  one  might 
place  the  hands  with  the  palms  together,  and  the  fingers  pointing  for- 
Avards.  Around  the  margins  of  the  labella,  under  low  power,  smaller 
and  larger  hair-like  processes  may  be  seen  projecting,  while  if  a 
labellum  be  removed  and  its  inner  surface  examined  under  the  micro- 
scope its  structure  will  be  found  to  be  elaborate  and  interesting. 

Figure  5  shows  the  inner  surface  of  the  right  labellum.  with  its 
lower  or  ventral  wall  at  vzv^  and  the  dorsal  margin  at  dm.  It  will  be 
seen  that  there  are  five  strong  chitinous  teeth,  ct,  and  a  series  of 
chitinous  blades,  cb.  which  are  more  delicate.     In  addition  to  these 


OHIO    STATE    BOARD    OF    HEALTH.  85* 

there  are  a  number  of  longer  or  shorter  setae  on  the  distal  and  ventral 
margins. 

The  labruni,  or  upper  lip,  {lb.  Figs.  2,  3,  and  4)  reaches  nearly 
to  the  base  of  the  labella.  Its  shape  in  section  is  readily  seen  from 
Fig.  3,  lb,  where  it  will  be  noticed  that  its  lateral  margins  are  incurved 
below  to  form  a  definite  tube  with  a  rather  broad  slit.  When  feeding 
the  tube  is  completed  by  the  hypopharynx.  (hp,  in  Figs.  2,  3,  and  4.) 
The  labrum  is  thickened  at  the  base,  is  somewhat  strongly  chitinised, 
and  has  a  sharp,  flattened,  triangular,  and  highly  chitinised  point.  At 
intervals  along  the  inner  surface  are  sense  organs,  each  supplied  with 
a  short  clear  hair. 

The  hypopharynx  is  as  long  as  the  labrum,  and  consists,  until  its 
distal  end  is  neared,  of  a  tube.  (Fig.  3,  hp.)  The  apical  part,  how- 
ever, is  flattened  and  membranous,  and  is  quite  unsuited  for  piercing, 
and  it  is  thought  that  it  serves  to  hinder  the  return  flow  of  tlie  saliva. 

METHOD  01'    FEEDING. 

When  about  to  feed  Stomoxys  calcitrans  raises  the  body  some- 
what higher  than  the  normal  position  on  the  legs,  and  brings  the 
proboscis  into  practically  a  vertical  position.  The  posterior  part  of 
the  body  is,  in  some  cases,  decidedly  elevated.  The  tip  of  the  proboscis 
is  in  this  manner  brought  into  contact  with  the  skin,  and  the  first 
puncture  made. 

This,  I  believe,  is  performed  by  the  labella,  which  are  slightly 
parted  so  that  the  teeth  and  blades  can  be  brought  into  operation.  If 
blood  emerges  from  the  puncture  it  is  sucked  up,  but  if  not,  I  imagine 
the  labella  are  depressed  laterally  and  the  point  of  the  labrum  forced 
into  the  host.  I  have  observed  on  several  occasions,  when  allowing 
this  fly  to  bite,  that  there  is  often  a  decided  stab  after  the  first  punc- 
ture has  been  made. 

The  saliva  is  conducted  to  the  wound  by  means  of  the  hypo- 
pharynx,  into  the  base  of  which  the  salivary  duct  opens,  {sd.  in  Figs. 
2  and  4,  sc.  in  Fig.  3.) 

The  blood  is  conveyed  to  the  pharynx  by  means  of  the  tube  formed 
by  the  labrum  and  hypopharynx  combined,  which  is  in  turn  enclosed 
by  the  dorsal  groove  of  the  labium. 

The  pharynx  proper  has  chitinised  walls  and  powerful  muscles, 
and  is  well  adapted  for  sucking. 

DIGESTIVE  SYSTEM. 

The  relative  position  of  the  different  parts  of  the  alimentary  canal 
in  Stomoxys  calcitrans  are  shown,  in  diagrammatic  form,  in  Plate  TIT, 


36  MONTHLY    BULLETIN 

Fig.  5.  Beginning  with  the  proboscis  it  will  be  seen  to  consist  of  the 
following  parts :  pr.  the  proboscis,  including  the  tube  formed  by  the 
labruni  and  hypopharynx.  g.  the  tube  leading  from  this  canal  to  the 
pharynx  proper,  ph.  the  pharynx  proper,  oe.  the  oesophagus,  which 
passes  through  the  brain  at  the  point  indicated,  prov.  the  proventric- 
ulus,  from  which  two  ducts  pass  backward,  viz. :  d.  ss,  the  duct  of  the 
sucking  stomach,  and  the  one  dorsal  to  this  which  is  the  thoracic  in- 
testine, s.  St.,  the  sucking  stomach,  i.  the  abdominal  intestine,  i,  Mt., 
the  junction  of  the  abdominal  intestine  and  the  proctodaeum,  at  which 
point  the  Malpighian  tubes  enter,  r.  the  rectum,  which  becomes  nar- 
rowed posteriorly  into  the  anus. 

The  food  canal  of  the  proboscis  was  described  earlier  in  the 
paper,  and  this  leads  to  a  sausage-shaped  tube,  which  has  chitinous, 
and  spirally-thickened  walls,  and  which  is  plainly  seen  in  the  mem- 
branous cone  when  the  proboscis  is  extended  for  feeding.  See  Plate 
IV.,  Figs  2  and  4.  g.) 

This,  in  turn,  opens  into  the  pharynx,  which  is  roughly  triangular 
in  shape,  having  its  upper  edges  drawn  out  into  chitinous  projections 
as  muscle  attachments. 

The-  oesophagus,  on  emerging  from  the  pharynx,  is  wide  and 
flattened,  but  soon  becomes  narrower  and  assumes  a  cylindrical  form. 
It  passes  slightly  forward  and  upward,  turns  abruptly  backward 
through  the  brain  and  into  the  thorax,  where  it  enters  the  ventral, 
anterior  part  of  the  proventriculus.  The  proventriculus  is  situated  in 
the  anterior  third  of  the  thorax,  and,  when  seen  from  above,  is  a 
delicate  white  sac,  circular  in  outline.  It  is  roughly  the  shape  of  a 
mushroom,  with  its  convex  surface  upward.  The  intestine  arises  from 
its  posterior  upper  surface,  while  the  oesophagus  enters  the  ventral 
surface.  Slightly  posterior  to  this  again,  on  the  ventral  surface,  the 
duct  of  the  sucking  stomach  arises. 

During  its  course  through  the  thorax  the  intestine  is  practically 
of  uniform  thickness,  but  at  about  the  point  where  it  passes  over  the 
sucking  stomach  it  becomes  thicker,  its  walls  at  the  same  time  be- 
coming thinner.  The  abdominal  intestine  is  approximately  three  times 
the  length  of  the  fly.  The  thickened  part,  i.  e.,  that  nearest  the  suck- 
ing stomach,  is  the  only  part  coiled,  and  this  lies  in  three  simple, 
superposed  coils,  gradually  narrowing  to  each  end.  Posterior  to  this 
the  intestine  continues,  of  practically  uniform  thickness,  to  the  rectum. 

The  rectum  is  a  transparent  sac,  cone-shaped,  with  the  apex  to- 
ward the  anus.  It  contains  four  rectal  glands,  which  are  long  and 
trumpet  like  in  shape,  and  terminates  in  a  narrow  tube  leading  to  the 
anus. 


OHIO  STATE  BOARD  OF  HEALTH.  37 

The  appendages  of  the  alimentary  canal  are  the  sucking  stomach 
the  salivary  glands,  with  their  ducts,  and  the  Malpighian  tubes.  The 
sucking  stomach,  when  filled  with  blood,  occupies  the  greater  part  of 
the  abdomen,  but  when  examined  before  the  insect  has  fed,  it  lies  in 
the  anterior  third,  immediately  above  the  salivary  glands.  Its  walls 
are  thin,  being  composed  of  a  single  layer  of  cells,  with  interrupted 
strands  of  muscle  fibre. 

The  salivary  glands  (Plate  III,  Fig.  6  sg.)  are  situated  partly  in 
the  thorax  and  partly  in  the  abdomen.  Their  two  ducts  arise  from 
the  common  salivary  duct  of  the  head,  and  follow  a  parallel  course 
through  the  thorax  until  the  abdomen  is  reached.  Here  they  become 
somewhat  wider  apart,  and  then  make  a  sharp  turn  outward  and  for- 
ward. Their  extreme  ends  are  slightly  enlarged.  Throughout  their 
whole  course  they  occupy  a  ventral  position  to  the  remainder  of  the 
alimentary  canal. 

The  Malpighian  tubes  (Plate  III,  Fig.  6.  M.t.)  are  long,  slender, 
and  much  coiled.  They  are  readily  seen  in  dissections,  being  easily 
distinguished  by  their  opaque  and  yellowish  appearance.  They  arise 
from  the  narrow  lower  intestine,  a  single  tube  on  each  side.  From 
each  of  these,  in  turn,  two  tubules  branch,  those  of  the  left  side  only 
being  shown  in  the  figure.  The  ends  of  the  tubules  on  the  right  side 
have  no  such  thickened  ends,  and  lie  in  a  ventral  position,  while  those 
of  the  left  take  a  dorsal  turn. 

THE   CIRCULATORY   SYSTEM. 

The  circulatory  system  in  Stomoxys  calcitrans  consists,  as  in 
other  Diptera,  of  the  dorsal  vessel  or  heart,  and  its  anterior  contin- 
uation, the  thoracic  aorta.  The  dorsal  vessel  extends  as  a  delicate  tube 
from  the  posterior  part  of  the  abdomen  to  its  anterior  sixth,  that  is 
above  the  anterior  part  of  the  sucking  stomach,  where  it  becomes 
narrowed  into  the  thoracic  aorta.  This  narrowed  portion  continues  of 
uniform  thickness  until  the  proventriculus  is  reached,  where  it  be- 
comes somewhat  flattened  and  wider.  Beyond  this  it  becomes  nar- 
rower, and  terminates  above  the  esophagus,  between  the  proventriculus 
and  the  neck. 

It  may  be  noticed  that,  as  found  by  Professor  Minchin  in  his 
study  of  Glossina  sp.,  the  dorsal  vessel  ends  blindly  behind,  is  com- 
posed of  similar  giant  cells,  and  has  similar  ostia  and  alary  muscles. 
The  number  of  chambers  in  the  heart  was  not  determined  with  cer- 
tainty, but  I  think  Tulloch  was  correct  in  supposing  that  there  were 
four.  The  dorsal  vessel  lies  free  in  the  pericardial  cavity,  but  is 
supported  by  the  muscular  pericardinal  septum. 


38  MONTHLY    BULLETIN 


NERVOUS   SYSTEM. 


There  are  two  chief  ganglia,  viz. :  the  brain  and  the  thoracic 
ganghon,  and  from  these  the  main  nerve-trunks  arise.  Time  was  not 
taken  to  work  out  the  more  minute  nerves,  but  the  following  may  be 
mentioned.  The  chief  nerves  of  the  head  beyond  those  of  the  com- 
pound eyes,  are  those  which  enervate  (a)  the  antennae,  (b)  the  ocelli, 
and  (c)  the  esophagus,  pharynx,  and  the  pharyngeal  muscles. 

The  brain  is  connected  with  the  thoracic  ganglion  by  commissures, 
between  which  the  esophagus  passes.  The  thoracic  ganglion  is  roughly 
pear-shaped,  and  is  supported  by  the  internal  chitinous  skeleton  of  the 
thorax.  The  main  nerves  given  off  from  the  thoracic  ganglion  are 
(a)  six  pairs  which  supply  the  thoracic  muscles,  and  (b)  the  ab- 
dominal nerve  trunk,  which  arises  as  a  stout  continuation  of  the  pos- 
terior part  of  the  ganglion.  This  nerve  trunk  gives  off  fine  branches 
to  the  abdominal  muscles  and  on  reaching  the  third  abdominal  segment, 
splits  into  three. 

These  three  branches  supply  the  reproductive  organs,  the  ovaries 
or  testes,  and  the  ovipositor  or  the  penis. 

REPRODUCTIVE   SYSTEM. 

The  male  generative  organs,  (Plate  III,  Fig.  7)  are  comparatively 
simple  in  structure.  They  are  however  not  readily  seen  in  gross  dis- 
section until  some  of  the  surrounding  and  over-lying  Malpighian 
tubules  are  moved.  They  consist  of  a  penis,  ejaculatory  duct,  vesicula 
seminalis,  and  testes  with  their  ducts. 

The  testes  are  smooth,  spherical  bodies,  enclosed  in  sacs  which 
have  deeply  pigmented  walls,  giving  them  a  deep  orange  color.  From 
the  lower  end  of  each  testis  a  delicate  tube  arises,  short  and  straight, 
which  runs  down  to  join  the  duct  from  the  opposite  side,  as  the  upper 
limbs  of  a  Y. 

From  this  junction  an  exceedingly  short  length  of  common  duct 
enters  the  bulbous  upper  end  of  the  tubular  organ,  which  would  seem 
to  serve  as  a  vesicula  seminalis.  This  is  a  flexible  tube,  often  seen 
lying  with  one  or  two  U-shaped  bends  in  its  course.  At  its  upper  end 
this  vesicula  seminalis  is  bulbous,  gradually  narrowing  below  to  form 
the  ejaculatory  duct,  (Fig.  7,  ed),  which  crosses  the  rectum  dor- 
sally  from  left  to  right,  to  enter  the  penis  in  front  of  it. 

The  female  reproductive  organs,  (Plate  III.  Fig  8)  are  of  the 
house  fly  type.  There  are  two  ovaries,  each  consisting  of  some  60 
ovarioles.  The  ovaries  vary  in  size  according  to  the  degree  of  ma- 
turity of  the  lowest  ova,  of  which  there  are  never  more  than  four  in  a 


OHIO    STATE    BOARD    OF    HEALTH.  39 

single  ovariole.  In  some  cases  the  ovaries  occupy  more  than  half  of 
the  whole  abdominal  space.  The  ovarioles  from  one  side  open  into  a 
wide  tubular  duct  which  joins  the  similar  duct  from  the  other  side 
like  the  arms  of  a  Y. 

As  a  result  of  this  junction  a  common  oviduct  (o.  v.)  results, 
which  runs  down  forming  a  long  third  limb  to  the  Y.  Below  the 
attachment  of  the  uterine  appendages  the  oviduct  continues  as  the 
uterus.  The  appendages  consist  of  the  uterine  glands  and  the  re- 
ceptacula  seminis. 

The  uterine  glands,  (u.  g.),  are  two  rather  stout  tubular  organs 
with  slightly  bulbous  extremities.  The  bulbous  end  is  firmly  joined 
to  the  lateral  oviduct  by  a  very  short  double  strain  of  connective  tissue. 

The  receptacula  seminis  are  two  small,  black,  spherical  bodies, 
each  with  a  cellular  socket  resembling  the  fitting  of  an  acorn  cup. 
From  this  runs  a  very  fine  duct  which  enters  the  division  between 
the  oviduct  and  the  uterus  in  the  mid-dorsal  line.  The  receptacula 
are  attached  to  each  other  but  can  be  separated  by  dissection.  The 
uterus  is  a  tube  of  the  same  diameter  as  the  common  oviduct  above, 
and  runs  down  the  middle  line  into  the  ovipositor. 

The  ovipositor  consists  of  three  cylindrical  segments  of  thin  chitin 
which  usually  lie  telescoped  inside  the  abdomen. 

TRANSMISSION   EXPERIMENTS. 

^Following  the  experiments  on  the  transmission  of  acute  poliomye- 
litis by  the  methods  outlined  above,  we  determined  to  undertake 
others  exactly  similar  to  those  performed  by  Rosenau-and  Brues,  and 
Anderson  and  Frost.  The  large  breeding  cage  mentioned  previously 
was  used,  and  Stomoxys  calcitrans  collected  and  placed  therein.  The 
flies  died  rapidly  and  in  large  numbers,  but  the  total  number  was  kept 
up  to  the  three  hundred  mark  by  frequent  additions.  After  a  short 
experience  it  was  found  that  moistening  the  sides  of  the  cage  pre- 
vented to  a  large  extent  the  numerous  deaths  among  the  flies. 

On  June  17th,  1913,  a  small  monkey  of  the  Rhesus  variety  was 
inoculated  subdurally  with  a  suspension  of  virus  in  salt  solution  (Virus 
Flexner  ex  No.  19).  The  animal  was  wrapped  securely  in  chicken 
wire  of  2-inch  mesh,  and  allowed  to  remain  in  the  cage  for  two  hours 
on  the  day  of  inoculation,  and  daily  thereafter  until  his  death  on  June 
23rd.  Four  healthy  monkeys,  (Nos.  25,  26,  28,  29)  of  the  same  variety 
were  wrapped  separately  in  chicken  wire  on  the  17th  inst.  and  placed 
in  the  cage  for  two  hours,  and  the  same  procedure  was  gone  through 
daily.     On  June  22nd,  a  second  animal   (Rhesus  No.  24)  was  inocu- 


40 


MONTHLY   BULLETIN 


lated  subdurally  with  the  same  virus  (Flexner,  ex  No.  19)  and  placed 
in  the  cage  for  the  same  period  daily.  The  animals  so  inoculated  were 
usually  placed  in  the  cage  in  the  early  morning,  and  the  healthy 
monkeys  at  a  later  period  in  the  day,  so  that  there  was  no  contact  of 
healthy  and  inoculated  animals.  The  flies  were  observed  to  feed  freely 
upon  the  monkeys,  and  also  upon  feces  and  urine  discharged  into  the 
bottom  of  the  cage.  Temperatures  of  all  the  monkeys  were  taken 
dailv  and  are  tabulated  below. 


Rhesus  No.  27. 
June  17.     Inoculated : 

Temperature. 
A.  M.  102.4 


I.       INOCULATED   MONKEYS. 


Virus  Flexner  ex.  No.  19. 


Temperature. 
P.  M.  103.6 


18. 
19, 
20. 
21. 
22. 
23. 


Dead 


102.2    

101.6    

103.0  very  sick,  nervous 

104.0  paralyzed  on  left  side 

Post-mortem    examination    made. 


101.4 
103.2 
102.2 
101.6 
103.4 
Typical    infiltrative    lesions 


found  in  the  cord. 


Rhesus  No.  24. 

June  22.     Inoculated,  virus  Flexner,  ex.  No.  19. 


Temperature. 


Temperature. 

22.    A.M.    102.4    P.M.  101.8 

28.  "     "     101.6    "    "  103.0 

24.  "     "     104.2  sick,   irritable    "     "  104.4 

25.  "    "     103.6  weak,  verj^  nervous "     "  105.0 

26.  "    "    104.6-105.3   . . . .' "    "  105.6 

27.  "     "     104.4  left  side  paralyzed "    "  105.2 

2S.       "    "     104.4  completely  paralyzed    "    "  103.6 

29.  Dead.     Post-mortem  examination  made  on  this  date,  and  typical  in- 
filtrative lesions  of  acute  poliomyelitis  found  in  the  cord. 


The  virus  used  was  a  strain  obtained  from  the  Rockefeller  Insti- 
tute through  the  kindness  of  Flexner.  We  employed  this  virus  rather 
than  our  own  because  the  virus  used  by  Rosenau  and  Brues  was 
obtained  from  the  same  source. 


2.       HEALTHY   MONKEYS. 

Rhesus  No.  25. 

The  temperature  of  this  monkey  was  taken  twice  daily  beginning 
on  June  12th,  and  showed  no  abnormal  character  until  the  17th  instant 
when  exposure  to  the  cage  flies  was  begun. 


OHIO    STATE   BOARD   OF    HEALTH.  41 


June  17. 
18. 

Tempe 
A.  M. 

«       a 
«       a 

((       (( 
«       « 
«       « 

«       <( 
«       « 
if       (( 

«       a 

■rature. 
101.8   

Tent 
P. 

per 
M. 

« 
« 

ature. 
101.8 

102.4  

102.4 

19. 

101  6 

102.4 

20. 

101.0  

102.0 

21. 

100.4 

102.8 

22. 

100.4  

101.0 

23 

102  4  

102.8 

24. 

102  4  

102.2 

25. 

102.4  

«' 

102.6 

26. 

102.4  

101.4 

27. 

101.8  

101.6 

28 

102  0  

101.2 

29. 

101  8  

102.0 

30. 

102.0  

101.2 

July    1. 
2. 

101.8  

101.4 

102.4  

102.6 

8. 

102.0  

101.0 

The  temperature  of  this  monkey  was  taken  daily  until  July  17th, 
and  the  animal  remained  under  observation  for  two  months  longer 
without  developing  symptoms  of  any  illness  whatsoever.  The  other 
three  animals  in  this  ;series  were  subjected  to  the  same  observations, 
and  temperatures  were  taken  for  at  least  thirty  days.  Rhesus  No.  26 
succumbed  to  tuberculous  infection  late  in  September,  and  a  thorough 
examination  revealed  no  lesions  in  the  cord  or  brain. 

Rhesus  No.  26. 

Junel7.  A.  M.  102.0    ....'...... P.  M.  102.6 

18.  "  "  102.6  "  "  102.4 

19.  "  "  102.2  "  "  103.0 

20.  "  "  101.6 "  ■"  102.0 

21.  "  "  100.8  "  "  102.2 

22.  "  "  100.6  "  "  101.6 

23.  "  "  102.0  "  "  103.2 

24.  "  "  101.0  "  "  102.4 

25.  "  "  101.8  "  "  102.8 

26.  "  "  102.6 "  "  102.6 

27.  "  "  101.6  ■ "  "  102.4 

28.  "  "  103.2  "  "  102.8 

29.  "  "  102.2  "  "  102.4 

30.  "  "  102.4 "  "  102.0 

July    1.  "  "  103.0  "  "  103.2 

2.      "    "    101.8 "    "    101.6 

8.      "    "    101.4 "    "    101.6 


42 


MONTHLY    BULLETIN 


Rhesus  No.  28. 

June  18. 

A.  M 

19. 

fi    11 

20. 

t(    i( 

21. 

<(    <( 

22. 

((         u 

23. 

"    " 

24. 

<(      <( 

25. 

«      (1 

26. 

<(      « 

27. 

"    " 

28. 

"    " 

29. 

«      « 

30. 

((      f( 

July     1, 

"     " 

2. 

"     " 

3. 

<(      (f 

Rhesus  No.  29. 

June  18. 

A.  M 

19. 

20. 

21. 

22. 

23. 

24. 

25. 

26. 

27. 

28. 

29. 

30. 

July     1. 

2. 

3. 

103.8 
102.6 
102.2 
101.6 
102.6 
102.2 
102.6 
101.6 
101.2 
103.0 
101.6 
101.8 
101.6 
101.6 
102.0 


102 
102 
102, 
101 
103, 
102 
103, 
103 
103, 
104, 
103, 
103, 
103, 
103. 
102, 


P.  M.  102.4 

"  "  103.8  eye  inflamed 

"  "  102.4 

"  "  102.2 

"  "  102.0 

"  "  103.2 

"  "  103.0 

"  "  103.4  . 

"  "  102.0 

"  "  102.2 

"  "  102.4 

"  "  101.4 

"  "  101.4 

"  "  101.6 

"  "  101.4 
"102.2 


P.  M. 


103.8 
103.0 
101.4 
103.0 
101.4 
104.4 
103.2 
104.0 
104.2 
103.8 
103.2 
103.8 
103.2 
103.0 
103.2 
102.2 


Nothing  in  the  behavior  of  these  monkeys,  in  their  temperature 
curve,  or  in  their  subsequent  history,  would  lead  to  the  belief  that 
they  were  influenced  in  any  way  by  the  bites  of  the  supposedly  infected 
flies. 

EPIDEMIOLOGY, 


To  the  public  health  worker,  the  modes  of  transmission  of  acute 
poliomyelitis  are  the  most  important  features  of  the  disease,  as  it  is 
only  familiarity  with  these  that  will  lead  to  logical  methods  of  pre- 
vention. At  the  present  time  the  greatest  difficulty  consists  in  securing 
accurate  morbidity  and  mortality  reports,  and  accurate  data  concerning 
the  cases.    Unfortunately  it  is  only  those  cases  which  exhibit  paralysis 


OHIO    STATE    BOARD    OF    HEALTH.  43 

that  can  be  properly  diagnosed  and  reported  at  the  present  time, 
although  there  is  abundant  clinical  evidence  that  cases  with  no 
paralysis  are  due  to  the  same  infection  and  equal  or  outnumber 
frankly  paralyzed  cases.  While  we  are  still  in  the  dark,  to  a  large 
extent,  concerning  the  sources  and  modes  of  infection,  yet  recent 
work  has  shed  more  than  a  ray  of  light  on  the  subject.  No  one, 
apparently,  has  attempted  to  explain  the  unprecedented  movement 
of  acute  poliomyelitis  in  1907  from  Northern  Europe  to  the  United 
States  and  Canada,  although  Flexner  (16)  has  pointed  out  that  the 
two  foci  where  the  disease  largely  prevailed  during  that  year,  the 
Atlantic  Coast  cities,  and  the  state  of  Minnesota,  receive  the  bulk 
of  immigrant  population  from  Europe,  and  that  a  large  niajority 
of  those  from  Scandinavia  settle  in  Minnesota.  Why  the  disease 
should  confine  itself  to  Northern  Europe  for  a  long  period  and  then 
show  a  disposition  to  spread  rapidly  and  widely  has  not  been  ex- 
plained. The  opportunities  for  the  spread  of  acute  poliomyelitis 
from  Europe  to  this  country  appear  to  have  been  as  good  previous 
to  1907  as  during  that  year. 

When  the  disease  exists  in  a  state  or  city  it  does  not  spread  grad- 
ually but  appears  in  all  parts  practically  spontaneously.  It  is  true 
that  there  appear  to  be,  in  certain  localities,  foci,  from  which  the 
disease  spreads  radially,  but  the  spread  is  also  rapid  and  erratic.  In 
dealing  with  a  question  like  this  we  must  consider  the  facilities  for 
dissemination  and  compare  them  with  those  which  previously  existed. 
The  amount  of  railway  passenger  traffic,  especially  between  rural  points, 
has"*increased  out  of  all  proportion  to  the  increase  in  population  during 
the  last  few  years.  The  electric  lines  are  also  increasing  in  number 
and  honey-comb  the  rural  districts.  More  suggestive  than  these  is 
the  automobile,  whose  sales  have  increased  phenomenally  during  the 
last  live  or  six  years,  and  which  is  comparatively  almost  as  common 
in  rural  districts  as  in  cities.  By  the  use  of  these  vehicles  farmers 
are  brought  closer  to  their  neighbors  and  personal  contact  is  more 
common;  while  in  cities  and  states,  suburban  districts  are  brought 
nearer  to  the  center  of  the  city  and  the  boundaries  of  a  state  are 
brought  together.  In  this  connection  statistics  collected  by  the  Massa- 
chusetts State  Board  of  Health  follow.     (17.) 

Number  of  Auto- 
mobiles Registered,  Year. 

4,000 1904 

24,000  1909 

The  number  of  automobiles,  therefore,  increased  six  times  in 
five  years. 


44  ,  MONTHLY    BULLETIN 

In  Ohio  the  law  making  it  compulsory  to  register  automobiles 
did  not  go  into  effect  until  late  in  1908.  Statistics  of  the  number  of 
licenses  issued  in  succeeding  years  follow : 

Number  of  Auto- 
mobiles Registered.  Year. 

23,000  1909 

32,000  1910 

45,788 1911 

63,111  1912 

84,300  To  September  26,  1913 

The  number,  therefore,  will  have  increased  over  four  times  in 
five  years.  In  19 12  there  was  one  motor  driven  vehicle  to  every 
seventy-seven  people  in  this  state. 

The  possibility  of  this  enormous  increase  in  travel  having  some 
influence  upon  the  spread  of  acute  poliomyelitis  must  be  borne  in 
mind,  but  its  influence  is  to  some  extent  counteracted  by  the  fact 
that  travel  is  least  common  among  those  classes  of  individuals  most 
subject  to  the  disease,  those  under  six  years  of  age.  The  large 
number  of  indoor  places  of  amusement,  greatly  augmented  by  the 
use  of  motion  pictures,  may  also  exercise  some  influence  by  bringing 
together' carriers  of  the  virus  and  susceptible  individuals. 

Several  theories  have  been  advanced  to  explain  the  methods  of 
transmission  of  acute  poliomyelitis.     It  has  been  suggested  that  some 
of  the  lower  animals  may  act  as  reservoirs  without  themselves  show- 
ing appreciable  symptoms  of  the  disease;  or  that  it  might  be  a  disease 
of  lower  animals,  and  many  seemingly  convincing  histories  of  coinci- 
dent paralysis  in  animals  and  human  beings  have  been  recorded.    These 
do  not  usually  bear  the  light  of  scientific  investigation,  and  the  paralysis 
in  animals  has  not  been  found  to  be  due  to  a  typical  lesion  in  the 
spinal  cord.    The  theory  of  transmission  of  the  disease  by  stable  flies 
received  its  impetus  from  the  work  of  the  Massachusetts  State  Board 
of  Health,  and  more  especially  from  the  experiments  of  Rosenau  and 
Brues   (i).     A  field  investigation   (19)   of  the  prevalence  of  insects 
in  communities  where  the  disease  existed,  revealed  the  almost  con- 
stant presence  of  Stomoxys  calcitrans  Linn.,  or  biting  stable  fly,  a 
dipteron  greatly  resembling  Musca  domestica,  or  the  common  house 
fly,  but  differing  from  the  latter  in  that  it  is  able  to  pierce  the  skin 
of  animals  and  suck  blood.     Rosenau  and  Brues  in  October,   1912, 
were  able  to  announce  that  they  had  succeeded  in  transmitting  the 
disease  from  monkeys  sick  with  acute  poliomyelitis  to  healthy  animals 
of  the  same  kind.    The  sick  monkeys  were  exposed  daily  to  the  bites 
of  a  large  number  of  these  flies,  and  healthy  monkeys  were  after- 


OHIO  STATE  BOARD  OF  HEALTH.  45 

wards  exposed  to  the  bites  of  the  same  insects.  These  experiments 
were  performed  in  large  screened  cages  with  zinc  bottoms.  In 
monkeys  the  subjects  of  this  fly-borne  disease,  the  pathological  picture 
was  said  to  be  typical.  Anderson  and  .Frost  (2)  corroborated  this 
work  in  October,  1912,  and  were  able  by  intracerebral  inoculation,  to 
set  up  the  disease  in  another  generation  of  monkeys,  using  the  spinal 
cords  of  the  dead  monkeys  as  virus.  There  remained  the  question  as 
to  whether  the  bites  of  this  fly  constituted  the  sole  means  of  trans- 
mission, and  a  number  of  experiments  carried  out  in  our  laboratory 
and  under  conditions  that  eliminated  any  possible  transmission  except 
by  the  bites  of  these  flies,  not  only  failed  to  elucidate  this  point,  but 
did  not  substantiate  the  experiments  performed  by  previous  ob- 
servers in  any  particular.  Anderson  and  Frost  (20)  have  recently 
published  the  record  of  a  number  of  experiments  showing  that  only 
their  first  attempt  was  successful,  and  that  later  attempts  failed  com- 
pletely to  transmit  the  infection.  Some  criticism  of  the  experiments 
performed  by  Anderson  and  Frost,  and  Rosenau  and  Brues  is  offered 
in  the  light  of  our  own  experience  with  their  methods.  While  it  has 
not  been  found  possible  to  transmit  acute  poliomyelitis  by  the  contact 
of  a  sick  monkey  with  a  healthy  animal,  the  possibility  that  such  an. 
accident  might  take  place  must  be  considered  when  experimental 
evidence  of  this  nature  is  weighed.  Monkeys,  when  allowed  to  remain 
for  as  long  a  period  as  two  hours  in  a  cage,  discharge  faeces  and  urine 
and  allow  secretions  from  the  mouth  to  drop  on  the  floor.  The  num- 
ber of  infected  flies  in  the  cage  precludes  careful  cleaning  and  the 
secretions  and  discharges  evaporate,  and  are  probably,  to  some  extent 
at  least,  inhaled.  It  is  also  possible  that  the  monkeys  will  lick  the 
cool  metallic  floor,  when  thirsty.  An  experiment  first  performed 
successfully  by  Flexner  (16),  and  repeated  in  our  laboratory,  is  sig- 
nificant in  this  connection.  The  virus  of  acute  poliomyelitis  is  broken 
up  with  salt  solution  and  gently  brushed  on  the  intact  nasal  mucosa 
of  a  healthy  monkey.  Within  the  usual  period  of  incubation,  the 
animal  succumbs  to  the  infection  almost  as  certainly  as  if  inoculated 
by  the  intracerebral  route.  If  monkeys,  which  we  know  to  be  com- 
paratively insusceptible,  will  succumb  to  infection  so  surely  by  this 
method,  is  it  not  possible  that  contact  with  the  infected  discharges 
may  in  some  instances  set  up  the  disease?  It  was  observed  during 
our  experiments  that  the  stable  flies  would  suck  any  fluids  deposited 
on  the  floor  of  the  cage,  and  some  were  observed  to  feed  on  the  moist 
faeces.  The  virus  has  been  found  only  in  small  traces  in  the  blood, 
and  it  is  possible  that  the  flies  may  have  infected  the  healthy  monkeys 


4t)  MONTHLY    BULLETIN 

with  some  of  the  discharges  rather  than  the  blood.  The  arguments 
in  favor  of  the  transmission  of  acute  poliomyelitis  by  flies  are,  briefly, 
that  the  seasonal  prevalence  of  the  disease  is  greatest  when  the  insect 
life  is  at  its  height;  that  this  seasonal  distribution  is  identical  with 
that  of  insect-borne  disease;  and  that  the  biting  stable  fly  has  trans- 
mitted the  disease.  The  common  bed  bug  (Cimex  lectularious)  and 
house  fly  (Musca  domestica)  (29)  are  able  to  carry  the  virus  in  a 
living  state  for  some  time, — ^the  former  extracting  it  from  the  blood 
of  a  diseased  monkey,  and  the  latter  after  feeding  on  the  virus.  The 
arguments  against  the  theory  of  insect  transmission  are  that  the  dis- 
ease, while  its  greatest  incidence  is  in  the  summer  and  autumn  months, 
does  not  occur  in  little  community  outbreaks  surrounding  the  first  case, 
as  would  be  expected  and  as  is  the  case  with  other  insect-borne  dis- 
eases. So  far  the  experimental  evidence  has  implicated  no  insect 
which  fulfills  all  necessary  conditions.  The  work  of  Rosenau  and 
Erues,  and  Anderson  and  Frost  requires  more  extensive  confirmation 
and  application  to  the  human  form  of  the  disease  before  its  impor- 
tance can  be  properly  appreciated.  The  fact  that  in  our  laboratory 
the  same  species  of  monkey  were  infected  with  virus  from  the  same 
source  (Flexner)  renders  it  probable  that  if  fly  transmission  ever  does 
take  place,  it  is  an  unusual  and  difficult  procedure.  From  the  epidemio- 
logical side  we  are  not  acquainted  with  an  insect-borne  disease  which 
confines  its  ravages  almost  entirely  to  the  very  young.  Further,  the 
distribution  of  the  cases,  with  seemingly  no  epidemic  foci,  is  unlike 
that  of  any  other  insect-borne  disease  of  which  plague,  malaria,  yellow 
fever  and  possibly  typhus  f eVer  are  examples. 

The  theory  of  dust  conveyance  originated  by  Lovett  and  Richard- 
son (22)  and  later  actively  advocated  by  Hill  (22)  appears  to  be  losing 
ground.  It  is  true  that  the  virus  has  been  found  in  the  dust  of  a  room 
in  which  a  patient  in  the  acute  stage  of  poliomyelitis  was  confined  (2t,). 
It  is  quite  probable  that  under  such  circumstances  the  nasopharyngeal 
.  secretions  could  gain  access  to  the  dust.  It  has  been  suggested  that 
conveyance  by  dust  would  explain  the  greater  incidence  of  the  disease 
in  rural  communities,  where  the  roads  and  streets  are  not  paved  and 
watered;  while  on  the  other  hand,  good  pavements  and  well  watered 
streets  in  the  city  would  tend  to  reduce  the  number  of  cases  to  a  mini- 
mum. It  is  a  fact,  however,  which  must  not  be  forgotten,  that  in  prac- 
tically all  communicable  diseases  the  human  host  is  the  all  important 
reservoir  of  the  virus.  The  virus,  then,  must  gain  access  to  the  dust 
from  the  human  host  if  such  a  theory  is  tenable.  It  would  appear  that 
the  very  great  dilution  occurring  in  the  dust,  as  it  is  scattered  by  the 
wind,  would  render  the  amount  of  virus  liable  to  reach  any  individual, 


OHIO    STATE    BOARD    OF    HEALTH.  47 

negligible.  In  addition,  the  theory  of  dust  conveyance,  is  not  recon- 
cilable to  all  outbreaks.  In  Cincinnati  in  191 1,  for  instance,  the  epi- 
demic was  preceded  and  accompanied  by  unusually  heavy  precipitation, 
and  the  streets  were  also  watered  more  thoroughly  prior  to,  and  during 
the  outbreak  than  ever  before.  Hill  has  called  attention  to  the  fact 
that  in  Minnesota  certain  outbreaks  abated  rapidly  when  watering  the 
streets  was  begun,  while  in  other  situations  where  this  measure  was 
not  resorted  to  the  disease  continued  to  prevail.  This  is,  however, 
often  found,  and  appears  to  be  a  characteristic  of  acute  poliomyelitis, 
that  outbreaks  will  arise  and  fall  rapidly  and  erratically.  The  theory 
of  dust  conveyance  does  not  account  for  the  comparatively  large  num- 
ber of  children  under  six  who  are  attacked,  or  the  scarcity  of  secondary 
cases  in  a  family. 

Fomites  should  logically  be  considered  with  dust.     If  acute  polio- 
myelitis is  a  disease  in  which  the  parasite  or  virus  enters  and  leaves 
the  body  through  the  nasal  mucosa,  and  the  secretions  of  this  mem- 
brane contain  the  virus,  then  articles  soiled  with  these  secretions  are 
dangerous.     There  is  no  reason  to  suppose  that  such  articles  may  not 
play  a  part  in  so-called  contact  infection.     The  virus  has  been  found 
in  the  secretions  of  the  intestinal  tract  and  in  the  faeces,  and  the  con- 
sideration of  acute  poliomyelitis  as  a  disease  spread  by  this  means  is 
in  order.     Arnold  Josephson   (3)   was  able  to  detect  the  presence  of 
the  virus  on  a  handkerchief  and  fancy  work  used  by  patients  with 
acute  poliomyelitis.     In  a  series  of  cases  recorded  by  Wickman,  milk 
appears  to  have  been  the  source  of  infection.     Reginald  Farrar  (24) 
mentions  the  epidemic  at  Midlands,  which   followed  shortly  after  a 
large  amount  of  tub-closet  manure  had  been  distributed  through  the 
district.    The  manure  came  from  Nottingham,  where  an  unusual  num- 
ber of  cases  occurred  at  the  time.    The  seasonal  distribution  favors  the 
theory  of  transmission  by  means  of  the  alvine  discharges,  as  do  the 
facts  that  the  disease  is  frequently  ushered  in  with  gastro-intestinal 
symptoms,  and  that  monkeys  may  be  infected  by  feeding.     Intestinal 
lesions  have  been  described  in  acute  poliomyelitis  and  it  appears  that 
the  conception  of  infantile  paralysis  as  a  gastro-intestinal  infection  has 
been  neglected  to  some  extent.    It  is  true  that  from  the  epidemiological 
point  of  view,  no  convincing  data  has  been  collected  proving  that  acute 
poliomyelitis  has  ever  been  transmitted  by  articles  of  food  or  drink, 
other  than  the  instance  cited  above  from  the  work  of  Wickman.     The 
last,  and  in  our  opinion  the  most  logical  theor}'^  of  conveyance,  is  that 
the  disease  is  spread  by  personal  contact,  and  that  acute  cases,  missed, 
abortive  and  atypical  cases    (fulminant  types)    and  healthy   carriers 
transmit  the  disease  to  others.     This  view  was  strongly  supported  by 


48  MONTHLY    BULLETIN 

Wickman  and  has  since  had  for  its  proponents,  men  whose  experience 
with  acute  poliomyeHtis  is  of  the  widest  extent.  That  this  theory  has  at 
its  foundation  a  basis  of  fact,  is  evidenced  by  the  recent  work  of  Kling, 
Pettersson  and  Wernstedt,  and  Flexner  and  Clark,  who  demonstrated 
the  presence  of  the  virus  in  the  secretions,  nasal,  buccal,  tracheal  and 
intestinal,  of  acute  cases  dead  of  the  disease,  in  healthy  individuals  in 
connection  with  cases  and  in  abortive  and  atypical  cases.  The  former 
observers  further  showed  that  the  number  of  healthy  carriers  equals 
the  number  of  typical  cases  in  the  community.  This  work  placed 
infantile  paralysis  on  almost  the  same  plane  as  epidemic  cerebro-spinal 
fever,  in  so  far  as  transmission  is  concerned.  The  striking  resemblance 
between  these  two  epidemic  diseases  was  first  pointed  out  by  Flexner 
who  stated  that  in  his  opinion  infantile  paralysis  had  been  mistaken 
for  epidemic  meningitis  for  many  months  in  some  communities.  The 
age  of  the  patients,  location  of  the  principal  lesions  in  the  central 
nervous  system,  sites  of  entry  and  exit  of  the  causative  organisms,  the 
abundance  of  healthy  carriers  and  of  ambulant  and  abortive  cases  in 
the  presence  of  an  outbreak,  and  lastly,  the  scarcity  of  secondary  cases 
and  the  insusceptibility  of  a  large  part  of  the  population,  point  to  a 
relationship  more  or  less  intimate  between  these  two  epidemic  diseases. 
The  seasonal  prevalence  only  is  at  variance.  Frost  (25)  pointed  out 
that  in  epidemic  meningitis  we  have  a  disease  presumably  transmitted 
by  personal  contact,  yet  it  is  difficult  or  almost  impossible  to  trace  the 
connection  between  acute  cases.  One  author  (3)  considers  that  epi- 
demic meningitis  may  be  a  common  dise?.se  of  childhood  which  only 
in  an  extremely  limited  number  of  cases  localizes  in  the  nervous 
system  and  sets  up  the  manifestations  which  we  regard  as  character- 
istic of  the  disease.  This  conception  has  no  superabundance  of  evi- 
dence to  support  it. 

None  of  the  theories  thus  far  advanced  rest  on  secure  foundations 
of  fact.  The  factor  of  extremely  limited  susceptibility  of  a  large  part 
of  the  population  must  be  added  before  any  of  these  theories  are 
logical.  Data  on  this  point  must  be  collected  and  further  facts  ad- 
vanced before  any  special  theory  of  conveyance  is  given  preference. 
The  large  preponderance  of  evidence  is  certainly  in  favor  of  the  per- 
sonal contact  theory  but  the  whole  matter  is  to  be  regarded  as  some- 
what unsettled.  In  the  meantime  it  is  well  to  remember  that  in  the 
case  of  several  communicable  diseases,  no  one  method  of  transmission 
is  universal.  In  typhoid  fever,  food,  flies,  water  and  contact  all  play 
.an  important  part.  In  scarlet  fever,  while  contact  is  the  most  important 
factor,  fomites  and  milk  may  also  act  as  vehicles  of  transmission.  It 
is  entirely  possible  that  several  factors  may  play  a  part  in  the  trans- 


OHIO    STATE    BOARD    OF    HEALTH.  49 

mission  of  acute  poliomyelitis,  since  the  evidence  in  favor  of  any  one 
factor  to  the  exclusion  of  all  others  is  not  absolutely  convincing.  It  is, 
therefore,  clearly  our  duty  to  attack  not  one,  but  every  possible  source. 
Not  only  must  we  isolate  patients  and  contacts  and  destroy  the  naso- 
pharyngeal secretions,  but  the  house  of  the  patient  must  be  screened 
and  flies  destroyed,  stable  manure  removed  or  covered,  the  dust  laid  by 
water  or  oil  where  the  disease  is  epidemic,  and  the  stools  and  urine 
disinfected  as  if  their  source  were  a  typhoid  patient.  Only  by  attack- 
ing every  source  can  we  hope  to  destroy  the  vital  factor. 

ETIOLOGICAL   FACTOR. 

The  transmission  of  acute  poliomyelitis  to  monkeys  was  accom- 
plished in  1909,  independently,  by  workers  in  Europe  and  America. 
Before  this  practically  nothing  was  known  of  the  nature  of  the  organ- 
ism or  virus  which  set  up  the  disease,  but  its  successful  transmission 
in  1909  resulted  in  rapid  progress  along  this  line.  In  the  early  experi- 
ments bacteria  and  parasites  were  sought  for  in  the  nervous  tissues  of 
human  beings  and  monkeys  and  no  constant  findings  were  recorded. 
According  to  Flexner  (i6),  the  scarcity  of  polynuclear  leucocytes  in 
the  cerebro-spinal  fluid  and  spinal  cord,  and  the  comparatively  large 
number  of  mononuclear  cells  suggested  the  presence  of  a  protozoal 
parasite  rather  than  a  simple  bacterium.  The  fact  that  no  observers 
had  described  parasites  suggested  that  it  might  be  ultra-microscopic  and 
perhaps  filterable.  This  it  proved  to  be,  an  emulsion  of  the  spinal  cord 
of  a  paralyzed  monkey  centrifugalized  and  pressed  through  a  Berke- 
feldt  filter  being  capable  of  setting  up  the  disease  in  monkeys  on  intra- 
cerebral inoculation.  The  virus  even  passes  through  the  fine  pores  of 
the  Chamberland  filter,  although  with  some  difficulty.  It  is,  therefore, 
intermediate  in  size  between  the  largest  and  smallest  virus  belonging 
to  this  class,  and  passes  more  readily  through  the  coarser  pores  of  a 
Heim  filter  than  through  the  finer  varieties.  The  virus  is  highly  re- 
sistant to  drying,  light  and  chemical  action.  Like  the  virus  of  rabies, 
it  withstands  the  dehydrating  action  of  glycerine  for  many  months, 
but  unlike  the  latter  resists  the  action  of  caustic  potash  (KOH)  for 
long  periods  without  marked  attenuation.  It  is  highly  resistant  to  0.5% 
carbolic  acid,  but  its  easily  destroyed  by  heat,  an  exposure  of  30  min- 
utes to  a  temperature  of  50°  C.  removing  its  activity.  Menthol,  hydro- 
gen peroxide,  and  corrosive  sublimate  in  dilute  solutions  destroy  the 
virus  very  effectively,  and  the  use  of  one  of  these  is  recommended  in 
the  sick  room.  A  temperature  of  2°  C.  to  4°  C.  for  several  weeks 
<ioes  not  impair  its  strength,  and  even  when  the  spinal  cord  undergoes 
4    A.  p. 


60  MONTHLY    BULLETIN 

autolysis  and  is  overgrown  with  mold  at  a  temperature  of  +4°  C., 
the  virus  is  unimpaired.  All  attempts  to  cultivate  the  parasite  of  acute 
poliomyelitis  met  with  failure  until  February,  1913,  when  Flexner  and 
Noguchi  (7)  announced  that  they  had  succeeded  in  cultivating  the 
parasite  in  vitro.  The  cultures  they  secured  were  virulent  for  monkeys 
although  in  one  instance  the  source  was  a  human  being,  and  in  another 
instance  a  monkey.  Visible  but  minute  colonies  were  obtained  on  the 
second  medium  they  employed  which  is  not  suited  for  direct  transfer 
of  the  virus  from  the  animal  tissues.  This  important  step  will  prob- 
ably be  the  means  of  adding  largely  to  our  knowledge  of  the  virus  of 
acute  poliomyelitis,  just  as  the  first  successful  transmission  of  the 
disease  to  monkeys  allowed  a  flood  of  light  to  fall  upon  a  hitherto 
almost  unknown  infection. 

One  other  point  deserves  mention.  The  virus,  if  enclosed  in 
protein  matter,  resists  the  light  and  drying  processes  for  long  periods, 
and  has  been  found  in  the  dust  of  sick  rooms  and  on  handkerchiefs  and 
fancy  work.  The  common  house  fly  and  bed  bug  may  carry  the  active 
virus  for  several  days.- 

CULTIVATION    OF  THE    MICROORGANISM    CAUSING   EPIDEMIC 
POLIOMYELITIS. 

Flexner  and  Xoguchi  have  isolated  a  very  minute  organism  from 
the  nervous  tissues  of  human  beings  and  monkeys,  the  subjects  of  the 
natural  and  experimental  disease,  respectively.  In  some  instances 
these  tissues  were  fresh,  in  others  they  had  been  removed  for  some 
time  and  were  preserved  in  glycerine.  Sterile  ascetic  fluid  and  a  piece 
of  sterile  rabbit  kidney  formed  the  basis  of  the  medium  used,  and  two 
per  cent,  nutrient  agar  was  added  in  some  instances  to  solidify  the 
mixture.  Solid  pieces  of  nervous  tissue  were  inoculated  into  this 
medium  and  grown  under  anaerobic  conditions,  and  better  results  were 
secured  with  solid  particles  than  with  an  emulsion  of  the  brain.  In  a 
series  of  thirty-three  experiments  twenty-four  initial  cultures  were 
obtained.  It  was  found  impossible  to  obtain  the  initial  growth  on  the 
solid  medium,  which  was  successful  in  promoting  the  growth  of  trans- 
fers. From  a  series  of  experiments  in  which  human  nervous  tissue 
from  cases  of  poliomyelitis  was  used,  eight  successful  cultivations 
were  secured.  Sub-cultures  were  secured  in  nineteen  instances  from 
twenty-seven  initial  cultures.  On  the  solid  medium  the  colonies  appear 
as  gra)ash  bodies,  about  one-third  of  a  millimeter  in  diameter. 

If  these  colonies  are  smeared  and  the  stained  preparations  ex- 
amined under  the  microscope,  a  definite  grouping  of  the  organisms 
into  chains,  pairs  and  masses  is  observed.     The  individual  organisms 


OHIO    STATE    BOARD    OF    HEALTH.  51 

average  about  0.2  of  a  micron  in  diameter.  Giemsa's  and  Gram's  stain 
are  most  suitable  and  the  organism  is  irregularly  Gram  positive. 

The  cultures  obtained  from  human  and  animal  sources  were  inocu- 
lated subdurally  into  monkeys.  In  a  number  of  instances  these  inocu- 
lations vv^ere  successful  in  setting  up  the  experimental  disease,  and  the 
iiervous  tissues  of  these  animals  proved  capable  of  setting  up  the 
experiiiiental  disease  in  still  other  generations  of  monkeys. 

In  view  of  these  facts  the  authors  conclude,  "that  an  etiological 
relationship  has  been  shown  to  exist  between  the  cultivated  micro- 
organism and  epidemic  poliomyelitis  as  it  occurs  in  human  beings  or  in 
monkeys."  *  *  *  "This  organism  exists  in  the  infectious  and  dis- 
eased organs ;  it  is  not,  as  far  as  is  known,  a  common  saprophyte,  or 
associated  wath  any  other  pathological  condition ;  it  is  capable  of  re- 
producing on  inoculation,  the  experimental  disease  in  monkeys,  from 
which  animals  it  can  be  recovered  in  pure  culture.  And  besides  these 
classical  requirements,  the  microorganism  withstands  preservation  and 
glycerination  as  does  the  ordinary  virus  of  poliomyelitis  within  the 
nervous  organs.  Finally,  the  anaerobic  nature  of  the  microorganism 
interposes  no  obstacle  to  its  acceptance  as  the  causative  agent,  since 
the  living  tissues  are  devoid  of  free  oxygen  and  the  virus  has  not  yet 
been  detected  in  the  circulating  blood  or  cerebrospinal  fluid  of  human 
beings,  in  which  the  oxygen  is  less  firmly  bound;  nor  need  it,  even 
should  the  microorganism  be  found  sometimes  to  survive  in  these 
fluids." 

>  PATHOLOGY. 

The  manner  of  ingress  and  exit  of  the  virus  is  of  vital  importance, 
as  only  by  a  knowledge  of  this  are  we  able  to  suggest  the  possible  mode 
of  conveyance  from  a  patient  stricken  with  the  disease  to  a  susceptible 
individual. 

The  virus  is  found  in  the  brain  and  cord,  in  the  secretions  and 
mucosa  of  the  nose  and  throat,  and  in  the  mucous  secretions  of  the 
trachea,  stomach  and  small  and  large  intestine.  It  has  not  been  de- 
tected in  any  of  the  important  organs.  Small  quantities  have  been 
found  in  the  mesenteric  glands  and  in  the  blood  and  cerebro-spinal 
fluid.  The  virus,  after  an  intra-cerebral  injection,  multiplies  in  the 
nervous  tissues ;  some  is  discharged  into  the  cerebro-spinal  fluid  and 
reaches  the  blood  and  lymphatic  channels.  It  is  probable  that  the  blood 
exerts  an  inhibitory  action  on  the  virus,  as  it  can  be  recovered  from 
this  fluid  only  in  minute  quantities.  By  means  of  the  lymphatics  the 
virus  is  carried  into  the  cerebrum  with  the  fine  olfactory  nerves,  and 
is  constantly  found  in  this  situation.     Some  of  the  virus  is  swallowed 


62  MONTHLY    BULLETIN 

and  found  in  the  stomach  and  the  secretions  of  the  large  and  small 
intestine.  It  is  to  be  presumed  that  the  greater  part  is  to  be  found  in 
the  naso-pharynx,  and  it  is  probable  that  a  multiplication  and  increase 
takes  place  in  the  nasal  mucosa. 

It  has  been  demonstrated  in  this  and  other  laboratories  that  the 
virus  in  saline  suspension,  brushed  gently  over  the  intact  nasal  mucosa 
of  a  monkey,  will  set  up  the  infection  almost  as  surely  as  if  by  intra- 
cerebral injection.  According  to  Flexner  (i6),  if  the  monkey  so 
inoculated  be  sacrificed  in  forty-eight  hours,  the  olfactory  lobes  alone 
are  found  to  contain  the  virus.  If  the  blood  distributed  the  virus,  the 
medulla  and  spinal  cord  would  have  become  infective,  rather  than  the 
olfactory  lobes,  since  they  exhibit  a  greater  affinity  for  the  virus.  In 
this  connection  it  is  well  to  note  that  inoculation  into  the  spinal  nerves 
serves  to  set  up  the  disease  after  a  more  or  less  lengthy  period  of 
incubation,  dependent  upon  the  distance  of  the  site  of  inoculation  from 
the  cord  and  brain. 

The  virus  is  contained  in  the  naso-pharyngeal  secretions  and  may 
easily  be  distributed  in  speaking,  sneezing  and  coughing.  In  this  con- 
nection it  is  well  to  remember  that  as  far  as  our  present  knowledge 
goes,  diphtheria,  scarlet  fever  and  epidemic  meningitis  are  all  children's 
diseases,  and  the  naso-pharyngeal  mode  of  ingress  and  egress  obtains 
for  them'  all. 

Another  interesting  point  in  the  pathology  of  acute  poliomyelitis 
has  to  do  with  the  specific  selective  action  of  the  virus  in  localizing 
in  the  anterior  horns  of  the  gray  matter  of  the  cord,  especially  at  the 
cervical  and  lumbar  enlargements.  The  greatest  damage  is  certainly 
done  to  the  anterior  horns  in  the  large  majority  of  cases,  although  it  is 
not  believed  as  formerly  thought,  that  the  meninges  and  other  parts  of 
the  cord  do  not  likewise  suffer  to  a  minor  degree.  It  has  been  fre- 
quently pointed  out  that  as  a  vascular  disturbance  is  the  fundamental 
change  in  acute  poliomyelitis,  so  those  parts  of  the  cord  with  the  most 
liberal  blood  supply  will  suffer  the  most.  It  is,  of  course,  true  that  the 
cervical  and  lumbar  enlargements  and  anterior  horns  possess  the  most 
abundant  blood  supply,  and  these  parts  are  most  frequently  affected. 

The  question  as  to  whether  the  virus  exerts  a  direct  toxic  action 
upon  the  vessel  walls  or  whether  the  disturbance  is  due  to  the  mechan- 
ical action  of  the  thick  collar  of  cells  which  surround  them  in  this 
disease  is  still  undecided.  The  occlusion  of  the  vessels  by  mechanical 
means  and  the  resultant  anemia  appears  sufficient  to  cause  a  degenera- 
tion of  the  cells  in  the  area  supplied  by  the  affected  vessels.  On  the 
other  hand,  it  is  impossible  to  rule  out  the  toxic  factor  which  may 
have  something  to  do  with  the  changes  in  the  vessel  wall  and  the  con- 


OHIO    STATE    BOARD    OF    HEALTH.  bo 

sequent  hemorrhages,  and  it  is  quite  possible,  even  probable,  that  both 
these  factors,  mechanical  and  toxic,  play  a  part  in  setting  up  the  minute 
changes  in  the  nervous  system,  the  results  of  which  we  recognize  as 
the  clinical  manifestations  of  acute  poliomyelitis. 

The  development  of  our  knowledge  of  the  pathology  of  poliomye- 
litis has  passed  through  several  stages.  The  first  conception  was 
based  upon  a  study  of  material  secured  some  time  after  the  acute  siage 
of  the  disease  had  passed,  when  an  atrophic  change  was  apparently  the 
characteristic  lesion.  Charcot  (27),  in  1870,  considered  a  primary 
degeneration  of  the  anterior  horn  cells  to  be  the  specific  change.  Next 
the  conception  that  the  changes  in  the  nervous  system,  as  now  known 
to  exist,  constituted  the  whole  pathology,  assumed  the  foreground. 
Finally  the  conception  that  acute  poliomyelitis  was  an  infectious  dis- 
ease, and  as  such,  reasoning  from  analogy,  would  cause  extensive 
changes  involving  the  central  nervous  system  and  the  important  organs 
of  the  body,  came  to  the  fore,  and  has  done  much  to  elucidate  the 
nature  and  course  of  the  disease.  Closer  study  has  shown  that  the 
anterior  horns  do  not  suffer  alone,  but  that  the  intervertebral  ganglia, 
peripheral  nerves,  meninges  and  brain  all  share  in  the  changes  caused 
by  the  interaction  of  virus  and  nervous  tissue.  As  being  of  primary 
importance,  the  changes  occurring  in  the  cord  and  brain  will  be  de- 
scribed first. 

Changes  in  the  Nervous  System.  As  with  other  infections,  the 
changes  naturally  vary  from  edema  and  beginning  infiltration  to  exten- 
sive degeneration  of  the  anterior  horn  cells  and  the  formation  of  scar 
tissue.  In  death  in  the  acute  stage,  the  meninges  are  found  to  be 
edematous  and  injected,  with  little  if  any  increase  in  the  cerebro-spinal 
fluid.  On  section  the  cord  proper  projects  and  is  edematous  and 
softened,  moist  and  darker  than  normal.  The  gray  matter  stands  out 
clearly  and  may  present  minute  hemorrhages.  There  is  no  exudate 
visible  on  the  membranes. 

Microscopically,  the  membranes  present  a  marked  perivascular 
infiltration  with  mononuclear  cells,  which  appear  to  cling  closely  to 
the  vessel  wall  and  are  contained  in  lymphatic  spaces  surrounding  the 
vessels.  The  same  change  is  present  in  the  vessels  of  the  cord,  espe- 
cially those  entering  the  anterior  horns,  and  the  hyperaemia  is  marked. 
Hemorrhages  may  be  a  striking  feature,  but  are  sometimes  absent  even 
in  severe  cases.  Edema  is  one  of  the  first  and  most  prominent  changes. 
These  changes  are  not  confined  to  the  anterior  gray  matter,  but  are 
present  throughout  the  anterior  half  of  the  cord.  In  cases  of  any 
standing  degeneration  of  the  anterior  horn  cells  is  marked, — indeed  in 
the  usual  case,  hyperaemia,  infiltration,  hemorrhages  and  degeneration 


54  MONTHLY    BULLETIN 

are  the  striking  changes.  Neurophages  are  a  frequent  finding,  and  a 
single  cell  may  contain  a  number  of  degenerated  nerve  cells,  in  still 
older  cases  the  nerve  cells  may  be  diminished  in  number  or  altogether 
absent  on  one  or  both  sides,  and  in  these  cases  the  formation  of  scar 
tissue  completely  fills  the  space  formerly  occupied  by  the  anterior  horn. 

All  these  changes  occur,  to  a  lesser  degree,  in  the  cerebrum,  cere- 
bellum, medulla  and  pons.  Exactly  similar  changes  occur  in  the 
nervous  tissue  of  the  posterior  root  ganglia,  and  are  of  almost  constant 
occurrence.     Cellular  infiltration  is  also  found  along  the  nerve  roots. 

The  changes  in  other  organs  and  parts  of  the  body  are  not  so 
striking,  but  in  eleven  cases  examined  by  Feabody,  Draper  and  Dochez 
(28),  were  found  to  be  practically  as  constant.  These  cases  all  showed 
an  involvement  of  the  lymphoidal  tissue  throughout  the  body,  and  of 
parenchymatous  organs.  Marked  swelling  occurred  in  Peyer's  patches 
and  the  mesenteric  lymph  modes.  Definite  enlargement  of  the  sub- 
sternal, bronchial,  cervical,  axillary  and  inguinal  lymph  glands,  and  the 
tonsils,  was  also  noted.  The  spleen  may  be  enlarged  and  on  section 
the  clearly  marked  Malpighian  corpuscles  stand  out.  Lymphoid  tissue 
appears  to  be  affected  similarly  throughout  the  body.  Microscopically, 
a  pale  inner  or  central  zone,  consisting  largely  of  endothelial  cells,  is 
surrounded  by  closely  packed  masses  of  lymphocytes.  The  endothelial 
cells  stain  faintly,  and  are  markedly  phagocytic.  Some  areas  show 
extensive  necrosis  and  are  invaded  by  polynuclear  leucocytes. 

Cloudy  swelling  of  the  parenchymatous  organs  is  frequently  met 
with.  In  the  liver,  however,  more  striking  changes  occur,  consisting 
of  lesions  in  circumscribed  areas  in  which  degeneration  of  liver  cells 
and  infiltration  of  lymphoid  and  polynuclear  cells  have  taken  place. 
Where  the  degeneration  is  severe,  early  fibrous  tissue  makes  its  appear- 
ance, and  all  the  lesions  of  a  beginning  cirrhosis  are  displayed. 
Admirable  plates  illustrating  these  conditions  are  found  in  the  work 
of  Draper,  Peabody  and  Dochez,  from  which  the  description  of 
changes  in  the  lymphoid  and  parenchymatous  tissues  is  adapted.  "That 
these  changes  in  the  lymphoid  tissues  and  in  the  liver  are  in  fact,  a 
part  of  the  reaction  of  the  body  to  the  virus  of  poliomyelitis,  would 
seem  to  be  made  certain  by  the  fact  that  exactly  similar  lesions  may  be 
found  in  the  organs  of  monkeys  which  have  been  experimentally  in- 
fected with  the  disease."     (Mono.  4,  p.  25.) 

The  recognition  of  acute  poliomyelitis  as  a  general  infection  is  a 
distinct  step  in  advance,  and  places  our  conception  of  the  disease  on  a 
sound  basis. 


OHIO    STATE    BOAllD    OF    HEALTH.  55 

SYMPTOMOLOGY. 

The  disease  may  be  conveniently  divided  into  the  following  stages : 

1.  Period  of  incubation. 

2.  Prodromal  stage. 

3.  -  Stage  of  paralysis. 

4.  Stage  of  convalescence  with  gradual  retrogression  of  paralysis. 
It  is  also  customary  and  wise  to  classify  the  different  forms  of  the 

disease  so  as  to  possess  a  skeleton  on  which  to  form  a  conception  of 
the  disease  as  a  whole.  As  one  form  of  the  disease  blends  almost  in- 
sensibly into  another,  it  is  difficult  to  decide  upon  a  rational  method  of 
classification.  That  formulated  by  Wickman,  although  serving  a  use- 
ful purpose  by  directing  attention  to  the  meningitic,  abortive  and  so- 
called  cerebral  forms  of  the  disease,  is  neither  rational  nor  scientific 
at  the  present  time,  having  for  a  basis  neither  the  anatomy  nor  the 
pathology  of  the  disease.  A  much  more  logical  and  simpler  classifica- 
tion follows.     Cases  are  divided  into: 

1.  Those  in  which  the  lower  motor  neurone  is  involved. 

2.  Those  in  which  the  upper  motor  neurone  is  involved. 

3.  Those  in  which  both  upper  and  lower  motor  neurones  are 

involved. 

4.  Abortive  cases. 

Draper,  Peabody  and  Dochez  suggest  the  following  useful  classi- 
fication : 

1.  Abortive  cases. 

2.  Cerebral  group. 

3.  Bulbo-spinal  group. 

The  group  of  bulbo-spinal  cases  includes  all  in  which  the  lower 
motor  neurone  is  involved,  whether  the  lesion  is  situated  in  the  medulla 
and  involves  cranial  nerves,  or  in  the  anterior  horns  and  involves  spinal 
nerves.  A  flaccid  paralysis,  with  the  electrical  reaction  of  degeneration, 
impaired  nutrition  or  atrophy  of  the  muscles,  and  loss  of  tendon  re- 
flexes, is  the  type.  The  cerebral  group  includes  all  cases  with  a  spastic 
paralysis,  due  to  involvement  of  the  upper  motor  neurone.  Such  cases 
are  comparatively  rare,  but  have  been  proven  to  be  cases  of  acute 
poliomyelitis,  pure  and  simple.  Abortive  cases  include  all  in  which  a 
paralysis  does  not  develop,  and  evidence  is  increasing  that  such  cases 
equal  or  outnumber  cases  belonging  to  the  bulbo-spinal  group. 

PERIOD  OF  INCUBATION. 

The  length  of  the  period  of  incubation  in  human  beings  has  not 
been  definitely  determined.     In  the  experimental  disease  in  monkeys  it 


66  MONTHLY    BULLETIN 

extends  from  two  days  to  four  weeks,  the  average  being  from  six  to 
eight  days.  From  the  experience  of  various  other  observers  and  our 
own  observation,  the  length  of  the  period  of  incubation  in  human  cases 
might  fairly  be  stated  to  be  from  three  days  to  three  weeks,  with  an 
average  of  six  to  ten  days.  In  this  connection  it  should  be  pointed 
out  that  in  the  experimental  disease  the  length  of  the  period  varies 
inversely  with  the  size  of  the  dose  and  virulence  of  the  virus. 

PRODROMAL  STAGE. 

In  all  the  cases  observed  by  us,  a  definite  history  of  symptoms 
preceding  the  onset  of  paralysis  could  be  elicited.  In  many  cases 
these  were  not  of  sufficient  severity  to  alarm  the  parents  or  cause  them 
to  seek  the  services  of  a  physician.  In  others,  and  these  comprised 
by  no  means  an  inconsiderable  number,  the  prodromata  were  severe 
and  alarming,  and  physicians  were  called  in  early.  A  superficial 
inquiry  would  often  elicit  only  the  statement  that  the  child  went  to  bed 
perfectly  well  in  the  evening  and  in  the  morning  awoke  paralyzed.  In 
such  cases  a  definite  history  of  more  or  less  severe  prodromal  symp- 
toms may  be  secured  by  more  rigid  questioning.  The  reason  for  this 
is  that  the  sudden  paralysis  has  driven  out  of  the  minds  of  the  parents 
all  events  of  lesser  importance  which  preceded  this  catastrophe.  A 
history  will  often  reveal  that  for  several  days  preceding  paralysis  the 
child  had  not  been  feeling  well, — ^there  had  been  a  marked  change  in 
the  temperament.  Fever  was  present,  and  irritability  or  drowsiness,  or 
both,  were  remarked.  Often  these  symptoms  will  be  attributed  to  a 
fall  or  accident  of  some  kind.  A  feature  of  the  disease  noted  in  our 
cases  and  commented  upon  by  previous  observers,  is  that  the  character 
of  the  symptoms  may  vary  with  the  locality  and  the  epidemic.  In  one 
outbreak  of  nine  cases,  all  occurring  within  a  short  period  of  each 
other,  the  prodromata  were  marked  and  intense,  and  obstinate  consti- 
pation was  a  characteristic  of  every  case;  while  in  an  outbreak  about 
one  hundred  miles  distant,  the  prodromal  symptoms  were  slight  and 
the  absence  of  any  gastro-intestinal  disturbances  was  a  marked  feature. 

The  number  of  histories  which  contain  this  statement  is  remark- 
able,— "The  child  felt  well  and  played  around  as  usual  in  the  morning, 
but  in  the  afternoon  (or  evening)  lay  down  and  was  tired  and  fever- 
ish." There  were  only  a  comparatively  few  observed  by  us  in  which 
this  history  was  not  given.  In  other  words  the  onset  is  usually  sudden. 
In  thirty-six  cases  reported  to  us  by  physicians  the  onset  was  sudden, 
in  fourteen  cases  the  onset  was  gradual  and  in  two  cases  there  were 
remissions. 


OHIO    STATE    BOARD    OF    HEALTH.  0/ 

Adding  to  these  the  cases  observed  by  one  of  us,  we  find  that  in 
seventy-five  the  onset  was  sudden,  in  nineteen  gradual,  and  in  four 
remissions  occurred.  In  forty-seven  cases  reported  to  us  the  presence 
or  absence  of  a  chill  was  recorded.  It  was  present  in  thirteen  and 
absent  in  thirty-four  cases.  The  history  of  a  definite  chill  was  absent 
in  most  of  our  own  cases,  but  the  presence  of  chilly  sensations  in 
adults  was  noted  in  several  instances. 

Fever  was  perhaps  the  most  constant  feature  of  the  prodromal 
stage.  It  was  present  in  one  hundred  and  thirty-eight  of  the  one 
hundred  and  forty  cases, — in  one  it  was  denied  and  in  one  was  not 
noted. 

Only  in  a  very  limited  number  of  the  cases  wsis  the  temperature 
recorded  regularly,  so  that  it  is  difficult  to  show  the  typical  curve.  In 
general  it  persisted  until  the  paralysis  was  well  established  and  remitted 
as  soon  as  recovery  of  the  paralyzed  muscles  began.  Occasionally  a 
slight  elevation  of  temperature  persists  for  long  periods.  Usually  the 
fever  terminates  by  a  rather  sharp  lysis.  Peabody,  Draper  and  Dochez 
(28)  found  that  an  elevation  of  temperature  in  acute  poliomyelitis  is 
not  only  a  constant  feature,  but  is  also  of  short  duration.  Of  fifty- 
four  cases  four  had  a  temperature  of  from  100.6  degrees  F.  to  103.8 
degrees  F.  on  the  second  day,  eighteen  had  an  elevation  of  from  roo 
degrees  F.  to  104  degrees  F.  on  the  third  to  sixth  day  inclusive,  and 
four  showed  an  elevation  of  from  100  degrees  F.  to  105  degrees  F.  on 
the  seventh  day  to  tenth  day  inclusive.  After  the  fourth  day  only  1 1 
cases  carried  temperatures  over  99  degrees  F.,  while  twenty-five  had 
a  temperature  of  99  degrees  F.  or  less.  To  the  end  of  the  fourth  day 
fifteen  cases  had  temperatures  above  99  degrees  F.  and  only  three  99 
degrees  or  less. 

Two  charts  of  human  cases  and  two  of  the  experimental  disease 
follow. 


58 


MONTHLY    nULLETIX 
EXPERIMENTAL  DISEASE 


/  ^         3        ^         S        6         7        Q         9 

DAYS 


OHIO    STATE    UOARD    OK     HEALTH. 


59 


TWO  HUMAN  CASES 

DAVS 


€0  MONTHLY    BULLETiiS' 

Pain  appears  to  be  a  more  or  less  constant  feature  of  the  disease. 
On  account  of  the  extreme  youth  of  the  patients  a  history  of  spon- 
taneous pain  is  difficult  to  secure  in  the  majority  of  cases.  Pain  on 
movement,  or  evidence  of  fear  of  movement  is  practically  constant,  and 
suggests  hyperaesthesia,  which  is  one  of  the  most  constant  and  char- 
acteristic features  of  acute  poliomyelitis.  By  hyperaesthesia  we  do  not 
mean  an  increase  in  the  sensibility  of  the  skin  only,  but  rather  a  con- 
dition of  the  patient  in  which  his  whole  sensorium  is  abnormally  sensi- 
tive to  movement,  or  attempted  movement.  A  sudden  noise,  an  unex- 
pected touch,  or  a  rapid  movement  of  lights  and  shadows  causes  him 
to  start  violently.  It  is  a  condition  very  similar  to  that  found  in  cases 
of  strychnine  poisoning  where  a  sudden  noise  or  jar  throws  the  patient 
into  a  convulsion.  This  is  also  a  marked  feature  in  the  experimental 
disease.  A  sudden  tap  on  the  cage  will  set  up  a  series  of  quick  shaking 
movements  in  the  monkey,  resembling  convulsions,  accompanied  by  a 
series  of  quick,  sharp  barks,  in  which  the  element  of  fear  is  clearly 
to  be  distinguished.  Pain  was  present  in  ninety-six  of  our  cases  and 
its  distribution  varied  widely. 

Tenderness,  or  pain  on  pressure,  was  present  in  ninety-six  of 
our  one  hundred  and  forty  cases.  The  most  common  situation  was 
the  spine,  but  in  adults  it  was  found  to  exist  in  the  muscles.  In  chil- 
dren it  is  difficult  to  differentiate  cutaneous  hyperaesthesia,  ?)r  in- 
creased sensibility  of  the  skin,  from  true  tenderness  of  the  muscles. 
Restlessness  was  a  feature  of  one  hundred  and  ten  of  our  cases, 
and  drowsiness  was  present  in  seventy-four  instances.  In  fift}'  cases 
restlessness  and  drowsiness  alternated.  Drowsiness  varied  from  a 
disposition  to  sleep,  from  which  the  patient  could  be  easily  aroused,  to 
a  condition  of  deep  coma,  in  which  manipulation  only  caused  the  pa- 
tient to  cry  out,  immediately  relapsing  into  a  comatose  condition. 
Rolling  of  the  eyeballs,  and  tossing  of  the  head  sometimes  accom- 
panied this  condition. 

Retraction  of  the  head  was  present  in  seventy,  and  absent  in 
seventy  cases  of  our  series.  True  retraction  was  rare  in  the  patients 
obser\'ed  by  one  of  us  (F.  G.  B.)  ;  the  retraction  appearing  to  be  a 
voluntary  effort  of  the  patient  to  relieve  pressure.  In  other  cases  it 
was  thought  to  be  due  to  weakened  neck  muscles  and  little  objection 
was  offered  when  the  head  was  brought  forward  so  that  the  chin 
rested  on  the  sternum.  In  the  majority  of  instances,  however,  this 
manipulation  met  with  decided  resistance,  apparently  voluntary.  No 
dilatation  of  the  pupils  took  place  during  the  course  of  this  move- 
ment, such  as  is  observed  in  manv  cases  of  epidemic  meningitis. 

Sore   throat   has   often  .been   described   in   cases   of   acute   polio- 


OHIO    STATE    BOARD    OF    HEALTH.  61 

:niyelitis.  and  it  was  present  in  thirty-eight  of  otir  series.  It  was  slight 
in  every  instance.  In  some  cases  sore  throat  was  associated  with  en- 
largement of  the  tonsils,  The  mucous  membrane  in  these  cases  of 
sore  throat  usually  showed  a  slight  reddening  and  injection.  Bron- 
chitis has  been  described  as  occasionally  ushering  in  an  attack  of  acute 
poliomyelitis.  It  is  not  shown  in  our  case  histories.  By  other  writers 
its  occurrence  is  regarded  as  only  a  coincidence.  Coryza  was  present 
in  twelve  of  our  own  cases  at  the  outset. 

Castro-Intcstiiial  Disturbances.  Of  our  one  hundred  and  forty 
cases,  vomiting  occurred  in  sixty-eight  and  was  absent  in  seventy-two. 
In  the  majority  of  instances  it  occurred  only  once  or  twice  and  was 
not  marked  or  violent.     It  did  not  appear  to  be  projectile. 

Constipation  was  present  in  eighty,  and  absent  in  sixty-one  cases. 
In  eleven  it  was  obstinate  and  extended  over  a  period  of  several  days. 

Diarrhoea  was  recorded  in  twenty-seven,  and  absent  in  one  hun- 
dred and  thirteen  cases.  In  no  case  was  it  severe,  and  it  caused  little 
disturbance,  responding  readily  to  simple  remedies.  In  thirty-six 
cases  there  was  no  history  of  diarrhoea  or  constipation,  and  in  three 
cases  diarrhoea  and  constipation  alternated. 

Other  Nervous  Symptoms.  Nystagmus  was  present  in  two  of 
our  own  cases  and  one  of  the  reported  cases.  Athetoid  moA'ements 
of  the  limbs  were  a  feature  of  five  cases,  and  varied  from  fine  jerk}^ 
movements  to  a  condition  simulating  convulsions.  In  three  cases 
severe  general  convulsions  preceded  death.  In  two  others  general 
convulsions  were  present  before  the  onset  of  paralysis,  but  the  patients 
survived.  Retention  of  urine  was  present  in  five  cases  for  limited 
periods.  In  one  case  starting  movements  occurred  during  sleep,  and 
in  another  insomnia  was  marked  and  obstinate.  Rolling  of  the  head 
from  side  to  side  was  a  feature  of  several  cases  in  a  localized  out- 
break, and  in  this  series  a  patient  was  observed  whose  pupils  were 
"pin-point"  contracted,  although  no  drug  having  such  an  efifect  was 
given.  Twitching  movements  of  the  eyelids  and  muscles  of  the  face 
w-ere  not  unusual  in  the  cases  observed  by  one  of  us.  One  patient 
continually  licked  his  lips,  although  they  Avere  not  parched  or  the 
mouth  dry.  Intense  photophobia  was  a  feature  of  two  cases,  and  it 
was  present  in  two  other  cases  but  less  well  marked. 

Skin.  Profuse  sweating,  which  according  to  Miiller  (28).  is  of 
frequent  occurrence,  was  not  recorded  in  any  of  our  cases.  While 
sweating  was  present  in  some  patients,  it  was  no  more  profuse  than  is 
usual  in  patients  with  the  same  elevation  of  temperature. 

A  skin  eruption  was  present  in  two  cases.  In  one  the  rash  was 
maculo-papular.  distributed  over  the  entire  body,  and  appeared  during 


62  MONTHLY    BULLETIN 

the  prodromal  stage.     In  the  other  eczema  had  been  present  prior  to 
the  attack  and  was  accompanied  by  an  erythema. 

Length  of  Prodromal  Stage.  The  period  elapsing  between  the 
onset  of  acute  symptoms  and  the  onset  of  paralysis  is  known  as  the 
prodromal  stage.     Its  length  is  illustrated  in  the  following  table: 

Prodromal  Stage. 


Days    .... 

...1     1 

2 

3 

1 
4 

Cases    . . . 

...20 

37 

21 

18 

5  I  6       7 

I         I 

I         I 

8  1  6  1     3 


9  I  11 


12     14     20  j    30 

1  I     1  I     1  i       1 


Cases  considered  131. 

In  over  seventy  percent  of  one  hundred  and  thirty-one  cases  the 
prodromal  stage  did  not  persist  longer  than  four  days.  In  over  forty- 
three  percent  of  the  cases  its  duration  was  one  or  two  days. 

PARALYSIS. 

In  our  series  of  one  hundred  and  forty  cases  exact  details  of  the 
location  and  extent  of  paralysis  were  lacking  in  some  few  instances, 
in  which  the  case  was  not  seen  by  us.  This  is  particularly  true  of 
the  fulminating  type,  in  which  death  occurred  in  a  few  hours  or  Hays. 
Patients  who  died  of  a  respiratory  paralysis  were  often  said  to  be 
completely  paralyzed,  but  in  the  cases  personally  observed  by  us,  this 
was  by  no  means  always  true. 

A  table  showing  the  paralysis  in  our  cases  as  compared  with  the 
observations  of  other  authors  follows: 

Table  Compiled  From   Reports  of  Various   Authors   Showing   Comparative 
Location  of  Paralysis. 

Our  cases.-  Other  Authors. 

Both  legs   9    14  107    54  130  32  34G    30% 

Right  leg 25     15  63    81  216  8  158     14% 

Left  leg 7    27  62    37  239  8  380    33% 

Right  arm    5      9  5     11  5  0  35      3%; 

Left  arm  5      4  8      6  5  1  29      2% 

Both  arms 2      1  15  0  2  110.9%, 

All  four  extremities 5      2  .35      9  3  14  68      6% 

Arm  and  leg,  same  side 12  26      9  15  10  63      5% 

Arm  and  leg,  opposite  side 2       1  16  7  4  21       1% 

One  arm,  both  legs 0      0  10      5  2  G  23      2% 

Abdomen  with  other  paralysis 0       0  0       0  6  1  7  0.6% 

Total   1,141  cases. 


OHIO    STATE    BOARD    OF    HEALTH.  63 

In  the  above  table,  only  a  limited  number  of  our  own  cases  are 
included.     The  complete  list,  arranged  differently,  follows : 

Table  of   Paralysis. 

Both  legs 32 

Right  leg 8 

Let't  leg 8 

Total,   legs  alone 48 

Both  arms 2 

Right  arm 0 

Left  arm  1 

Total,  arms   alone ■  3 

All  four  extremities 14 

Arm  and  leg,  same  side 10 

Arm  and  leg,  opposite  side 4 

One  arm,  both  legs 6 

Both  arms,  one  leg 1 

Complete  paralysis    5 

All  extremities  and  respiration 4 

One  arm,  one  leg,  respiratory 2 

Both  legs,  right  arm,  and  tongue 1 

Both  legs,  both  arms  and  abdomen 1 

Both  legs,  right  arm,  respiration 1 

Both  legs,  right  arm,  deglutition 1 

All  extremities  and  one  eye. 1 

One  arm,  one  leg  and  face 1 

One  arm,  one  leg,  face,  e3'e 1 

Both  arms  and  respiration 1 

Face  and  arm,  left  1,  right  1 2 

Ptosis   and   arm 1 

Face  alone,  right  3,  left  2 5 

Not  given  21 

Abortive    , 6 

140 
Analyzing  this  table,  we  find: 

Legs,  one  or  both,  were  affected  in  101  cases. 
Arms,  one  or  both,  were  affected  in  59  cases. 
Face  or  eye  was  affected  in  11  cases. 

Spinal  Paralysis.  This  data  makes  it  evident  that  in  the  vast  ma- 
jority of  cases,  one  or  both  legs  are  aft'ected,  and  the  paralysis  is 
limited  to  the  legs  in  a  majority  of  the  patients.  The  lumbar  enlarge- 
ment of  the  cord  is  therefore  most  often  affected.  The  paralysis  in 
the  legs  is  of  two  main  types,  upper  and  lower, — that  affecting  the 


64  MONTHLY    BULLETIN 

muscles  of  the  thigh,  and  that  affecting  the  muscles  of  the  leg  and 
foot.  Talipes  was  naturally  the  most  frequent  deformity  noted,  and 
was  caused  by  the  unopposed  pull  of  the  flexors  of  the  foot,  which  in 
almost  all  cases  escape  the  residual  paralysis.  The  anterior  and 
peroneal  group  of  muscles  were  most  frequently  affected  in  this  type 
of  paralysis.  The  quadriceps  extensor  was  involved  more  frequently 
in  paralysis  of  the  upper  leg  than  any  other  muscle,  although  atrophy 
of  the  folds  of  the  buttock  showing  involvement  of  the  gluteal  group 
of  muscles  was  by  no  means  infrequent.  Although  complete  paralysis 
of  one  or  both  legs  is  not  uncommon  during  the  first  few  days  follow- 
ing the  onset,  the  danger  of  a  complete  and  permanent  paralysis  of 
this  nature  is  comparatively  small. 

Paralysis  of  the  arms  was  present  in  fifty-nine  of  our  cases.  In 
only  three  however,  were  the  arms  alone  involved.  Here  too,  a  com- 
plete and  permanent  paralysis  is  rare,  the  tendency  being  for  re- 
covery of  all  but  one  or  two  muscles,  or  groups  of  muscles.  The 
deltoid  appears  to  be  aft'ected  most  often  and  is  included  in  a  large 
majority  of  cases  of  upper  arm  paralysis.  This  muscle  also  shows 
atrophy  first,  its  position  being  such  that  any  atrophy  is  easily  noticed. 
A  loss  of  tone,  allowing  the  head  of  the  humerus  to  hang  loosely,, 
often  simulates  atrophy.  In  several  of  our  cases  extensive  atrophy 
of  one  or  both  deltoids  was  recorded.  In  several  cases,  in  which  the 
paralysis  was  of  the  lower  arm  type,  the  hands  showed  contractures, 
but  in  none  of  the  older  cases  was  there  any  permanent  deformity 
of  these  members. 

Respiratorx  Paralysis.  The  muscles  of  respiration  were  paralyzed 
in  twenty-six  cases,  and  in  all  of  them  death  ensued.  In  two  cases 
in  which  broncho-pneumonia  is  given  as  the  cause  of  death,  it  is 
possible  that  a  partial  respiratory  paralysis  may  have  been  the  con- 
tributing cause. 

The  diaphragm  is  supplied  by  the  phrenic  nerves,  the  lower  in- 
tercostal nerves,  and  the  phrenic  plexus  of  the  sympathetic.  The 
phrenic  nerve  arises  chiefly  from  the  fourth  cervical,  with  branches 
from  the  third  and  fifth.  While  the  nerves  supplying  the  muscles 
of  the  arms  and  shoulders  arise  below  this,  an  arm  paralysis  was 
found  in  almost  every  case  terminating  fatally  from  involvement  of 
the  muscles  of  respiration.  The  paralysis  in  such  cases,  was,  how- 
ever, usually  of  an  ascending  type,  and  involved  the  lumbar  cord 
previous  to  the  onset  of  paralysis  in  the  arms.  Two  of  our  reported 
cases  are  said  to  have  had  respiratory  paralysis  alone,  but  we  have 
not  been  able  to  confirm  this,  and  believe  that  the  general  picture  was 
obscured  by  the  rapid  progression  of  the  case  and  the  extent  of  the 


OHIO    STATE    BOARD   OF    HEALTH.  6& 

prostration.  It  has  been  shown  that  the  lumbar  enlargement  of  the 
cord  is  most  frequently  involved,  and  that  second  to  it  comes  in- 
volvement of  the  cervical  enlargement.  This,  we  assume,  is  due  to 
the  more  abundant  vascular  supply  in  these  situations.  For  this 
reason  the  intercostal  muscles  escape  in  the  large  majority  of  in- 
stances, as  is  also  the  case  with  the  diaphragm.  In  the  ascending 
form,  however,  these  situations  are  involved  in  turn,  although  a 
paralysis  of  the  arms  is  frequently  observed  prior  to  that  affecting 
the  intercostal  muscles,  and  this  in  turn  followed  by  a  further  as- 
cension and  involvement  of  the  third,  fourth  and  fifth  cervical  nerves 
with  a  consequent  paralysis  of  the  diaphragm.  Two  cases  of  paralysis 
of  the  diaphragm  of  over  a  week's  duration  were  observed  by  Pea- 
body,  Gay  and  Dochez.  and  recovery  occurred  in  both. 

Our  experience  in  paralysis  of  the  abdominal  muscles  is  limited, 
only  one  case  being  observed  in  our  series.  This  patient,  a  girl,  aged 
four,  one  month  following  the  acute  stage,  showed  a  bulging  of  the 
whole  left  side  of  the  abdomen  in  crying  and  laughing,  due  to  a 
paralysis  of  the  external  and  internal  oblique,  and  the  transversalis 
muscles.  There  was  also  a  paralysis  of  the  legs.  Recovery  was 
progressing  favorably. 

In  five  of  our  cases  paralysis  of  the  back  and  neck  muscles  was 
definitely  present.  In  many  others  the  presence  of  a  paralysis  in 
these  situations  was  suspected  during  the  acute  stage,  but  was  not 
definitely  determined.  Frost  (29)  states  that  the  muscles  of  the  back 
are  att'ected  oftener  than  is  supposed,  and  that  such  an  event  is  easily 
overlooked  as  it  occurs  dttring  the  acute  stage  when  the  patient  is  in 
bed.  A  paralysis  of  the  neck  was  found  in  quite  a  number  of  our 
own  cases  in  connection  with  paralysis  of  the  shoulders. 

Bulbar  Paralysis.  The  occurrence  of  a  bulbar  paralysis  alone 
was  first  noted  by  ^^ledin  (1890)  (29).  The  New  York  investiga- 
tion committee  (29)  found  it  mtich  more  frequent  than  the  experi- 
ence of  previous  observers  would  lead  one  to  expect.  A  list  of  their 
cases  follows : 

Facial    27 

Eyelids 18 

Eye  muscles  2G 

Speech 28 

Total  number  examined 700 

In  our  own  cases,  thirteen  instances  of  paralysis  of  muscles  de- 
riving their  nerve  supply  from  the  medulla  oblongata  or  pons  were 

5     A.  p. 


66  MONTHLY    BULLETIN 

found.  In  five  it  was  the  only  form  of  paralysis  present,  and  the 
fact  that  these  were  true  cases  of  acute  poliomyelitis  was  proven  by 
their  course,  symptomatology  and  the  fact  that  they  all  occurred  in 
neighborhoods  where  the  disease  prevailed.  In  nine  cases  muscles 
supplied  by  the  facial  nerve  were  involved.  The  right  and  left  sides 
were  each  affected  four  times,  and  in  one  case  the  side  was  not  stated. 
The  muscles  of  deglutition  were  involved  in  two  instances,  the  eye 
muscles  in  two  and  the  tongue  in  one.  In  only  one  case  were  the 
eyelids  affected.  The  two  lower  branches  of  the  facial  nerve  were 
most  often  affected.  One  abducens  and  one  right  external  rectus 
paralysis  occurred.  We  found  no  instance  in  which  we  had  reason 
to  suspect  that  the  optic  nerve  was  involved,  nor,  in  a  series  espe- 
cially observed,  was  any  change  found  in  the  olfactory  nerves,  al- 
though their  involvement  might  have  been  expected  when  we  con- 
sider that  the  virus  affects  its  entrance  and  exit  with  the  lymphatics 
accompanying  these  nerves  through  the  cribriform  plate  of  the  eth- 
moid bone.     One  case  of  disturbance  of  speech  was  noted. 

FATAL  CASES. 

Separate  consideration  of  cases  terminating  fatally  appears 
illogical,  inasmuch  as  the  course  and  pathology  of  such  cases  differ  in 
no  wise  from  those  in  whom  recovery  or  improvement  take  place'.  In 
our  series  of  one  hundred  and  forty  cases,  twenty-nine  died,  death 
occurring  as  follows  following  the  acute  onset,  and  paralysis. 

Onset  to  Paralysis.  Paralysis  to  Death. 

4  cases 1  day  3  cases same  day 

10  cases 2  days  8    cases 1  day 

8  cases 3  days  8  cases. 2  days 

4  cases 4  days  2  cases 3  days 

1  case 6  days'  3  cases 4  days 

1  case 23  days  2  cases 5  days 

1  case same  day  1   case 7  days 

—  1  case 17  days 

29  1  case 2S'  days 

29 

DuR.\TioN  OF  Disease  in  Cases  Terminating  Fatally  from  Respiratory 

Paralysis. 

3  cases 2  days  2  cases 6  days 

5  cases 3  days  1  case 9  days 

9  cases 4  days  1  case 11  days 

5  cases 5  days 


OHIO    STATE    BOARD   OF    HEALTH.  67 

Pneumonia. 

1  case  died  in 8  days      1  case  died   in 34  days 

1  case   died  in 26  days 

One  case  observed  by  us  terminated  fatally  in  less  than  sixty  hours 
from  the  acute  onset,  which  was  sudden  and  well-marked.  A  post- 
mortem examination  was  made  and  the  cord  later  used  as  virus  in  some 
of  our  experiments  on  transmission. 

Excepting  in  so-called  fulminating  cases,  those  terminating  fatally 
did  not  appear  to  have  a  more  severe  illness  than  those  who  recovered. 
Death,  in  the  majority  of  instances,  is  simply  an  accident  due  to  the 
circumstance  that  the  sections  of  the  cord  innervating  respectively  the 
diaphragm  and  the  intercostal  nerves  are  invaded  s-ynchronously.  A 
review  of  the  data  does  not  appear  to  throw  any  light  upon  the  prog- 
nosis as  to  the  outcome  of  any  particular  case. 

xAges  of  Fatal  Cases. 

7  months 1  case  7    years 1  case 

1  year 1  case  9   years 3  cases 

2  years 10  cases      10  years 1  case 

3  years 3  cases      14  years 1  case 

4  years 4  oases  — 

5  years 3  cases  Total    29 

6  years 1  case 

Eighteen  were  females  and  eleven  males.  In  eighteen  cases  the 
onset  was  sudden,  in  ten  gradual  and  in  one  there  were  remissions.  The 
fever  was  high  in  three  instances,  moderate  in  fifteen,  slight  in  ten 
and  absent  in  one.  \'omiting  occurred  in  twenty  of  the  cases.  Of 
other  symptoms,  restlessness  was  the  most  constant,  and  was  present 
in  all  of  the  twenty-nine  cases  at  one  stage  or  another.  Neither  the 
profoundly  stuperose,  nor  those  in  whom  restlessness  was  most  marked, 
died.  Usually,  as  noted  by  Peabody,  Draper  and  Dochez,  a  peculiarly 
alert  condition  precedes  death  by  respiratory  paralysis,  and  all  move- 
ment is  resented.  The  mind  is  clear  until  respiration  becomes  very 
weak.  Retraction  of  the  head  was  present  in  twelve,  and  absent  in 
seventeen  of  the  cases.  Convulsions  involving  the  whole  body  preceded 
death  in  three  cases,  muscular  twitching,  of  the  neck,  eyelids  and  face 
was  present  in  three,  and  nystagmus  in  one  case.  The  paralysis  was  of 
the  ascending  type  in  at  least  five  cases.  In  sixteen  instances  the 
paralysis  involved  all  the  extremities,  and  in  one  the  face  was  included. 
In  one  case  both  legs  and  one  arm  were  paralyzed,  and  in  two,  one  leg 
and  one  arm,  of  the  cross  variety  were  involved.  The  arms  alone,  and 
the  legs  alone  were  said  to  be  paralyzed  in  two  instances. 


68  MONTHLY    HULLETIN 

Tendon  Reflexes. 

The  change  in  tendon  reflexes  was  recorded  in  only  a  few  of  the 
cases,  as  no  comparative  data  of  the  presence  or  absence  of  any 
changes  at  any  particular  stage  of  the  disease  could  be  obtained,  owing 
to  the  nature  of  the  investigation. 

In  common  with  other  investigators  we  found  the  patellar  reflex 
usually  exaggerated  in  the  early  stages,  and  almost  always  absent  just 
prior  to  the  onset  of  paralysis,  especially  in  the  limb  which  afterwards 
became  paralyzed.  In  abortive  cases  the  knee-jerks  are  extremely 
variable.  In  thirty-seven  cases  recorded  in  Alonograph  No.  4,  of  the 
Rockefeller  Institute,  the  knee-jerks  were  present  in  one  or  both  knees 
in  twenty-six,  and  absent  in  eleven  cases.  Both  were  found  exagger- 
ated in  three  paralytic  cases,  and  the  reflex  arc  was  intact  on  one  side 
and  broken  on  the  other  in  one  instance.  The  knee-jerk  on  the  un- 
affected limb  was  therefore  more  often  present  than  absent.  The  knee- 
jerks  return  with  the  stage  of  repair. 

Cerebral  Type. 

Striimpell  (30)  in  1885  was  the  first  to  direct  attention  to  the 
analogy  existing  between  certain  cerebral  palsies  in  children,  and  acute 
poliomyelitis.  Hemiplegia,  with  exaggerated  reflexes  and  reaction  of 
degeneration  was  the  type.  ]\Iedin  (31)  in  1898,  and  Harbitz^and 
Scheel  (28)  included  in  their  writings  a  description  of  cases  of  this 
kind.  The  fact  that  such  cases  are  in  some  instances  at  least,  true 
cases  of  acute  poliomyelitis,  is  proven  by  the  occurrence  of  typical 
flaccid  paralysis  of  the  monoplegic  type  in  the  same  patient  and  in 
other  members  of  the  family.  In  addition,  pathological  examination 
has  shown  in  several  instances,  that  the  histological  picture  is  typical 
of  acute  poliomyelitis.  Ataxia  has  been  noted  in  some  of  these  cases. 
Anderson  and  Frost  (32)  were  able  to  demonstrate  that  the  serum  of 
a  patient  with  paraplegia  of  the  legs,  was  capable  of  neutralizing  the 
active  virus.  Neither  in  Wickman's  series,  in  the  patients  studied  at 
the  Rockefeller  Hospital,  or  in  our  own  cases  was  a  cerebral  type  oi 
poliomyelitis  observed. 

Abortive  Type. 

Wickman  was  the  first  to  direct  attention  to  the  fact  that  patients 
in  whom  no  paralysis  occurred,  were  suffering  from  true  acute  polio- 
myelitis. All  investigators  of  experience  are  a  unit  in  declaring  that 
abortive  cases  are  probably  more  frequent  than  has  yet  been  discovered. 
Wickman  found  that  abortive  cases  represented  from  twenty-five  per 
cent,  to  lifty  per  cent,  of  the  total  incidence  of  acute  poliomyelitis.     It 


OIIJO    STATE    BOAIUJ    OF    HEALTH.  69 

is  now  well  established  that  abortive  cases  are  examples  of  true  acute 
poliomyelitis  and  are  both  frequent  and  important. 

Pasteur  noted  that  cases  presenting  the  same  symptoms  as  infan- 
tile paralysis  and  in  whom  no  paralysis  took  place,  occurred  with 
striking  frequency  in  connection  with  paralyzed  cases.  The  only  patho- 
logical difference  existing  between  a  paralyzed  and  abortive  case  is 
that  in  the  former  the  cerebro-spinal  axis  is  hot  so  deeply  involved  — 
the  remainder  of  the  process  is  identical  and  experimentally  it  has  been 
shown  that  monkeys  inoculated  with  the  virus  occasionally  develop  an 
abortive  form  of  the  disease  which  produces  an  immunity  to  further 
infection  with  active  virus.  Netter  and  Levaditi  (33),  and  Anderson 
and  Frost  (32)  showed  that  the  serum  of  patients  who  have  had 
abortive  attacks  is  capable  of  neutralizing  the  active  virus.  Similar 
experiments  carried  on  by  Peabody,  Draper  and  Dochez  (28)  were 
not  so  successful.  Frost  has  pointed  out  that  in  any  epidemic  all 
gradations  of  severity  are  seen,  and  the  truth  of  this  is  verified  by  any 
large  experience  with  the  disease.  Judging  by  analogy  with  other 
acute  infectious  diseases,  such  a  fact  appears  neither  unlikely  nor  far- 
fetched. We  know  that  cases  of  smallpox  and  scarlet  fever  occur 
without  any  eruption  and  that  cases  of  typhoid  fever  may  occur  without 
the  usual  type  of  continued  fever.  It  would  be  a  more  rational  analogy 
to  compare  cases  of  typhoid  which  perforate,  with  cases  of  poliomye- 
litis in  which  paralysis  occurs,  as  it  is  probable  that  abortive  forms  out- 
number frankly  paralyzed  cases. 

Anderson  (29)  found  in  an  epidemic  in  Polk  County,  Nebraska, 
86  cases,  of  whom  39,  or  44  per  cent,  had  no  paralysis.  In  150  cases 
investigated  by  the  Massachusetts  State  Board  of  Health,  49  probably 
abortive  cases  were  found. 

If,  then,  abortive  cases  are  so  frequent  and  so  important,  as  they 
probably  constitute  the  often  missing  link  between  typical  cases,  how 
are  we  to  recognize  and  deal  with  them?  Wickman  described  four 
types.  I.  Cases  which  run  the  course  of  a  generalinfection.  2.  Cases 
in  which  meningitis  symptoms  predominate.  3.  Cases  in  which  pain 
is  marked.    4.    Cases  with  disturbances  of  the  gastro-intestinal  system. 

There  is  no  reason  for  using  this  classification  except  that  it  may 
serve  as  a  reminder  of  the  varied  symptoms  to  be  sought  for.  Prac- 
tically, abortive  cases  differ  in  no  way  from  paralyzed  cases  except  in 
the  occurrence  of  this  accident.  With  a  disease  in  which  the  symptoms 
and  signs  of  the  prodromal  stage  are  so  indefinite  as  acute  poliomye- 
litis, it  is  probably  not  possible,  except  in  isolated  cases,  to  make  a 
correct  diagnosis  of  such  illnesses  where  the  disease  in  typical  form  is 
not  known  to  prevail.    Where  the  disease  exists,  however,  the  physi- 


70  MONTHLY    BULLETIN 

cian  should  be  on  the  alert,  and  if  laboratory  and  hospital  facilities 
are  at  his  command,  the  number  of  abortive  cases  which  escape  recog- 
nition should  be  minimal.  It  was  a  feature  of  two  of  our  abortive 
cases  that  the  prodromal  signs  and  symptoms  were  more  severe,  and 
the  prostration  greater,  than  that  of  the  others  who  became  paralyzed. 
The  severity  of  the  prodromata  does  not  appear  to  indicate  a  wide- 
spread and  permanent  paralysis,  and  mild  initial  symptoms  do  not 
promise  that  the  patient  will  escape  serious  deformity  or  death. 

THE  BLOOD. 

Conflicting  statements  regarding  the  blood  counts  have  been  made 
by  different  observers.  In  some  cases  a  leukopenia,  in  others  a 
leukocytosis  has  been  recorded.  La  Fetra  (28)  reported  that  in  six 
cases  he  found  a  leukocytosis  varying  from  13,400  to  20,600.  Gay 
and  Lucas  (34)  made  a  study  of  the  blood  in  children  and  monkeys. 
They  described  a  leukopenia  with  lymphocytosis,  but  the  white  count  in 
their  human  cases  was  never  less  than  7,800.  Miiller  (28)  found  a 
leukopenia  of  from  3,000  to  6,000  in  the  acute  stage.  Most  extensive 
studies  have  been  made  by  Peabody,  Draper  and  Dochez,  who  record 
the  results  of  blood  examination  of  fifty-nine  cases.  Their  results 
indicate  that  in  the  paralytic  stage  the  count  is  about  normal  with  a 
tendency  toward  the  upper  limits.  The  differential  counts  revealed  the 
presence  of  a  definite  polymorphonucleosis.  There  was  only  one  ex- 
ception to  this  rule.  The  percentage  of  lymphocytes  was  distinctly 
below  the  average  in  all  but  one  case.  The  transitional  and  large 
mononuclear  cell  counts  did  not  average  above  the  normal,  but  in  many 
cases  an  increase  in  the  number  of  eosinophils  was  found.  The  in- 
crease in  polymorphonuclears  averaged  15  to  20  per  cent.,  and  the 
diminution  in  lymphocytes  averaged  the  same  figure. 

CEREBROSPINAL    FLUID. 

Gay  and  Lucas  (34)  made  the  first  valuable  contribution  to  the 
study  of  the  cerebrospinal  fluid  in  acute  poliomyelitis.  They  studied 
the  .spinal  fluid  of  monkeys  in  all  stages,  and  the  fluids  of  eleven  human 
cases  in  the  paralytic  stage.  Their  cell  counts  per  cubic  millimeter  in 
these  cases  varied  from  fifty-five  to  one  hundred  and  eighty,  and  the 
percentage  of  mononuclears  from  seventy-five  to  one  hundred.  The 
presence  of  a  specific  antibody  was  sought  in  the  spinal  fluid  by  Woll- 
stein  and  others,  and  Sophian  reported  that  the  globulin  test  is  positive 
in  early  stages  of  the  disease. 

Repeated  lumbar  punctures  and  examinations  of  the  fluid  were 
made  by  Peabody,  Draper  and  Dochez  in  sixty-nine  cases.     Their  con- 


OHIO    STATE    I30AKD    OF    HEALTH.  71 

elusions  are  that  deviations  from  the  normal  exist  in  practically  all  cases 
during  the  first  few  weeks  after  the  onset.  The  earliest  fluids  showed 
an  increased  cell  count,  but  a  low  or  normal  globulin  content,  (No- 
guchi's  Method).  The  increase  in  cells  takes  place  almost  exclusively 
in  the  lymphocytes  and  large  mononuclears. 

After  the  first  two  weeks,  the  conditions  are  reversed,  and  the 
globulin  content  increases,  while  the  cell  count  diminishes.  These 
changes  also  occur  in  the  fluid  of  abortive  cases.  All  their  fluids  re- 
duced Fehling's  solution.  The  authors  point  out  that  while  the  exam- 
ination of  the  cerebrospinal  fluid  does  not  give  any  information  of 
specific  diagnostic  value,  it  is  of  great  assistance  as  an  aid  to  diagnosis, 
in  the  early  stages  and  in  abortive  cases.  No  unusual  increase  in  intra- 
spinal pressure  was  noted,  nor  was  any  abnormal  appearance  observed, 
such  as  opalescence,  so  that  gross  examination  is  useless.  When  the  legs 
are  involved  greater  changes  are  found  than  when  the  arms  alone  are 
afitected.  Frost  (29)  states  that  the  fluid  in  early  stages  is  opalescent. 
In  three  fluids  examined  by  us  no  definite  gross  change  was  noted. 
The  cell  count  was,  however,  high,  and  the  lymphocytes  and  large 
mononuclear  cells  predominated.  The  question  arises  as  to  whether  it 
is  advisable  to  draw  off  the  cerebro-spinal  fluid.  In  the  early  stages 
this  procedure  is  certainly  useful,  even  if  a  negative  result  is  obtained, 
as  such  an  examination  is  of  value  in  ruling  out  certain  other  con- 
ditions, such  as  meningitis.  When  paralysis  is  established  its  utility  is 
doubtful.  The  principal  aim  at  the  present  time  is  to  study  the  disease 
in  the  preparalytic  stage,  and  in  abortive  forms,  so  that  its  recognition 
may  be  hastened,  and  treatment  administered  before  damage  to  the 
motor  cells  is  irreparable. 

DIAGNOSrS. 

The  diagnosis  of  acute  poliomyelitis  offers  little  difficulty  after  the 
paralysis  has  appeared.  The  type  of  paralysis  is  one  affecting  the 
lower  motor  neurone,  in  which  the  limbs  are  flaccid,  the  deep  reflexes 
are  lost,  and  sensation  is  unimpaired.  Atrophy  of  the  muscles  usually 
clinches  the  diagnosis. 

.  The  history  of  febrile  reaction,  hyperaesthesia.  pain  on  passive 
motion,  and  certain  evidences  of  gastro-intestinal  disturbances,  while 
not  absolutely  characteristic  of  acute  poliomyelitis  should  be  of  help, 
and,  when  there  are  cases  in  the  neighborhood  should  warrant  the 
suspicion  of  acute  poliomyelitis.  The  physician  and  health  officer 
should  be  constantly  on  the  alert  for  abortive  cases  and  for  cases 
with  a  fleeting  paralysis. 


72  MONTHLY    BULLETIN 

Cerebral  and  bulbar  cases  may  not  be  recognized  unless  there 
occurs  synchronously  a  typical  flaccid  paralysis.  Here  again,  the  pres- 
ence of  typical  cases  in  the  neighborhood  and  the  definite  history  of 
preparalytic  disturbances  that  can  usually  be  elicited  should  serve  as 
a  warning  to  the  attending  physician. 

The  diseases  with  which  acute  poliomyelitis  is  most  likely  to  be 
confounded  are,  epidemic  meningitis,  multiple  neuritis,  rickets,  acute 
polyarthritis,  and  such  acute  affections  as  influenza  and  summer  com- 
plaint. The  only  disease  which  cannot  easily  be  differentiated  is  epi- 
demic meningitis,  and  perhaps  only  an  examination  of  the  cerebrospinal 
fluid  will  clear  up  a  difference  of  opinion  or  a  doubtful  case.  In 
rickets  and  rheumatism  the  joints  are  swollen  and  painful,  and  move- 
ment is  lacking  for  that  reason,  but  a  careful  examinaiifjii  wi'l  shuvv 
that  the  limbs  are  not  paralyzed.  Certain  cases  of  paralysis  following 
the  acute  diseases  of  childhood  may  confuse  the  observer.  Ir,  these 
sensation  is  usually  unimpaired  and  regression  of  paralysis  does  not 
occur  so  early.  The  paralysis  is  usually  spastic.  The  sequelae  are 
often  very  severe  consisting  of  epilepsy  or  idiocy.  In  any  doubtful 
case  it  may  be  wise  to  take  the  cerebrospinal  fluid  and  examine  the 
blood.  The  presence  of  a  lymphocytosis  in  the  latter  and  a  greatly 
increased  cell  count  in  the  former  is  sometimes  of  great  help,  and 
such  an  examination  Avill  serve  to  rule  cut  meningitis.  The  cerebro- 
spinal fluid  should  be  subjected  to  as  rigid  an  examination  as  possible, 
and  for  this  and  other  reasons  the  desirability  of  establishing  a  labora- 
tory in  situations  where  acute  poliomyelitis  is  prevalent   is  manifest. 

It  is  extremely  necessary  that  the  clinician  take  a  broad  view  of 
the  disease,  and  familiarity  with  its  pathology  is  essential.  The  fact 
that  different  types  of  the  disease  are  found  at  dift"erent  places, — that 
it  may  simulate  meningitis  and  cerebral  palsies,  and  the  frequency  of 
abortive  and  atypical  cases, — these  considerations  should  serve  to  put 
the  clinician  on  the  alert,  so  that  when  he  is  confronted  with  an 
aberrant  case  of  supposed  influenza,  or  a  very  minor  illness,  he  may 
bear  poliomyelitis  in  mind,  and  exclude  it  only  after  a  most  rigid  review 
of  the  facts  pro  and  con. 

The  effective  prophylaxis  and  treatment  of  poliomyelitis  in  the 
future,  especially  in  the  event  that  any  specific  treatment  is  found, 
will  depend  entirely  on  the  ability  of  the  clinician  to  diagnose  his 
cases  early  and  accurately. 

PROGNOSIS. 

At  the  present  stage  of  our  knowledge  it  is  impossible  to  accu- 
rately foretell  the  ultimate  result  of  the  disease  in  any  given  case. 


OHIO   STATE   BOARD   OF    HEALTH.  73 

or  whether  or  not  paralysis  will  supervene.  Abortive  cases  are  more 
frequent  than  was  formerly  thought  and  probably  equal  or  outnumber 
typical  cases.  In  a  given  case,  the  longer  the  onset  of  paralysis  is  de- 
layed, the  less  apt  is  the  patient  to  become  paralyzed.  It  is  practically 
impossible  to  forecast  the  result  of  the  paralysis,  whether  it  will  persist 
or  whether  ultimate  recovery  will  take  place.  In  our  cases  disappear- 
ance of  the  paralysis  took  place  in  approximately  twenty-five  percent 
of  the  cases.  This  corresponds  with  the  experience  of  the  Massa- 
chusetts State  Board  of  Health  in  an  intensive  study  of  one  hundred 
and  fifty  cases.  In  other  localities  the  percentage  of  recoveries  from 
paralysis  has  varied  from  five  to  thirty  percent.  It  is  impossible  to 
say  that  absolute  recovery  will  occur  or  what  extent  of  residual 
paralysis  will  persist  until  at  least  two  years  have  elapsed  since  the 
onset.  There  is  no  known  sign  which  signifies  the  onset  of  paralysis, 
neither  is  there  any  rule  by  which  we  can  determine  that  a  progressive 
paralysis  will  abate  at  any  given  time.  Young  children  are  more  apt 
to  recover  completely  from  paralysis  than  are  older  children  and  adults. 

The  prognosis  as  to  life  or  death  is  equally  dif^cult.  Mortality 
tables  show  that  the  lethal  rate  varies  from  ten  to  twenty-five  percent. 
Ten  percent  is  more  usual  than  the  higher  percentages,  and  the  mor- 
tality in  different  localities  and  different  epidemics  does  not  vary 
nearly  as  widely  as  in  epidemic  meningitis.  The  older  the  patient  the 
more  likely  is  the  attack  to  prove  fatal.  Wickman  found  the  per- 
centage of  deaths  in  patients  under  eleven  years  of  age  to  be  ii  .9,  and 
in  cases  between  the  ages  of  twelve  and  thirty-two,  27.6  per  cent. 

In  our  own  series  of  cases  the  oldest  child  who  died  was  fourteen 
years  of  age.  The  fourth  day  of  paralysis  was  the  most  fatal  in  our 
experience.  Cases  which  die  from  paralysis  of  respiration  almost 
invariably  have  one  or  both  deltoids  affected.  Nearly  all  the  patients  who 
were  comatose  recovered,  while  several  patients  who  did  not  appear 
very  sick,  died.  Where  an  ascending,  rapidly  progressive  type  of 
paralysis  is  noted  the  prognosis  of  a  fatal  result  can  be  made  with  some 
assurance.  Other  observers  state  that  none  of  the  profoundly  stuperose 
or  highly  irritable  cases  died.  The  so-called  fulminating  cases,  in 
which  marked  prostration  in  the  characteristic  feature,  usually  ter- 
minate fatally. 

Those  cases  in  which  a  paralysis  of  the  intercostals  or  diaphragm 
alone  occurs,  frequently  die  of  pneumonia. 

TREATMENT. 

There  is  no  specific  treatment  for  acute  poliomyelitis  known  at 
the  present  time.     Strengthening  and  prophylactic  measures  only  can 


74  MONTHLY    BULLETIN 

be  used.  It  was  pathetic  to  observe  that  a  large  number  of  the 
families  in  which  our  cases  occurred  would  buy  any  patent  and 
worthless  preparation  or  apparatus  which  came  to  their  attention, 
particularly  if  it  were  expensive.  An  absolutely  worthless  so-called 
electrical  apparatus  was  sold  to  many  at  prices   ranging  from  $io 

to  $35- 

Even  if  a  specific  treatment  were  evolved  at  the  present  time, 
it  is  doubtful  if  it  would  be  of  much  value,  as  a  large  majority  of  the 
cases  are  not  recognized  until  paralysis  has  set  in.  This  is  the  greatest 
need  at  present,  a  means  of  rendering  the  disease  recognizable  in 
the  pre-paralytic  stage. 

Flexner  showed  that  urotropin  (hexamethylenetetramin)  given 
by  mouth  could  be  found  in  minute  quantities  in  the  cerebrospinal 
fluid,  and  that  such  treatment  would  delay  or  prevent,  in  some  cases, 
the  onset  of  the  experimental  disease.  For  this  reason  it  has  been 
recommended  that  this  drug  be  given  to  children  who  have  been  ex- 
posed. It  should  be  given  in  small  doses  and  for  a  period  not  exceeding 
one  week.  The  action  of  subdural  injections  of  epinephrin  in  the 
experimental  disease  was  studied  by  Clark,  (35)  who  found  that  such 
injections  are  capable  of  improving  the  muscular  tone  of  the  paralyzed 
muscles  and  the  respiratory  movements,  and  in  some  cases  prolong 
life.  The  drug  did  not  bring  about  an  arrest  of  the  progress  of  the 
disease,  even  when  given  early,  and  has  no  specific  action  on  the 
virus.  Its  action  is  rather  in  controlling  exudation  by  its  eflfect  upon 
the  vascular  system  than  upon  the  virus  itself. 

The  treatment  of  a  case  is  symptomatic  rather  than  specific. 
Rest  is  strongly  indicated.  It  has  been  found  that  certain  cases  which 
showed  the  usual  prodromata,  and  then  appeared  to  recover  and 
actively  exercise,  soon  relapsed  and  became  paralyzed.  The  necessity 
of  rest  in  suspected  abortive  cases  is  therefore  obvious.  Rest  of  the 
patient  should  include  rest  of  the  paralyzed  limb,  which  may  be  placed 
on  pillows  or  enclosed  in  loose  bandages  with  a  splint.  During  the 
acute  stage,  the  diet  usual  to  patients  witli  febrile  affections  should  be 
given,  but  when  convalescence  begins,  a  more  liberal  diet  is  required, 
as  the  appetite  grows.  Bathing  and  all  attentions  requiring  movement 
of  the  patient  should  be  carried  out  with  the  greatest  tenderness,  as 
a  child  will  learn  to  dread  any  manipulation  that  once  caused  pain.  A 
moderate  purgation  seems  to  be  useful,  as  in  other  febrile  affections, 
and  diaphoresis  may  be  promoted  with  hot  packs,  etc. 

Measures  to  allay  the  pain  consist  in  hot  packs,  splints,  heat  in 
the  form  of  hot  water  bags  and  the  various  drugs.  The  latter  should 
not  be  administered  unless  the  former  fail,  and  then  only  mild  anal- 


OHIO  STATE  BOARD  OF  HEALTH.  75 

gesics  in  small  doses  exhibited.  Bromides  are  very  useful,  not  only 
to  quiet  irritation  and  lessen  hyperesthesia,  but  also  to  subdue  pain. 
Sometimes  asperin,  codeine,  phenacetin  and  morphine  are  necessary. 

A  room  in  which  quiet  may  be  maintained,  should  be  chosen,  and 
absolute  rest  allowed  during  the  acute  stage.  The  bed-clothes  should 
be  so  arranged  that  no  pressure  is  felt  by  paralyzed  members,  and 
everything  possible  done  to  prevent  the  development  of  deformity 
which  takes  place  early  and  rapidly.  Massage  and  other  manipulative 
treatment  should  not  be  begun  until  the  pain  will  allow.  In  hospitals 
a  trained  masseuse  may  be  secured  and  much  good  result.  Apparatus 
to  prevent  deformity  may  be  applied  at  night,  while  voluntary  move- 
ment should  be  encouraged  in  the  day  time.  This,  the  best  possible 
form  of  movement,  may  be  aided  by  games,  bells  attached  to  the 
paralyzed  limbs  and  by  immersion  in  a  hot  water  bath.  Heat  may 
be  useful  in  the  form  of  hot  air  or  baking.  Passive  movement  is 
secondary  in  value  only  to  the  voluntary  activity  of  the  child.  All 
these  measures  should  be  directed  to  preventing  contractures  and 
deformities,  and  to  maintaining  the  muscles  in  such  a  condition  that 
when  the  weakened  motor  cells  begin  to  send  out  feeble  impulses,  a 
healthy  and  responsive  meuiber  may  be  found. 

Electricity  does  not  appear  to  be  of  distinct  value,  but  may  be 
useful  in  maintaining  the  nutrition  of  paralyzed  parts.  It  is,  however, 
of  distinct  use  from  the  point  of  view  of  prognosis,  for  when  the 
response  to  the  galvanic  current  is  gone,  little  hope  can  be  held  out 
for  the  ultimate  recovery  of  paralyzed  members.  In  general  it  may 
be  said  that  if  response  to  the  faradic  current  returns  within  the  year, 
the  prognosis  for  ultimate  recovery  is  hopeful. 

The  efficacy  of  the  measures  outlined  above  depends  upon  the 
thoroughness  with  which  they  are  practised,  and  the  length  of  time 
that  they  are  persisted  in.  A  rapid  improvement  takes  place  during 
the  first  two  weeks  following  the  onset,  and  then  the  improvement 
becomes  more  gradual  until  it  may  be  almost  imperceptible.  Treat- 
ment should,  however,  be  persisted  in  until  at  least  eighteen  months 
have  elapsed  since  the  onset,  and  the  patient  should  not  be  given  up 
as  hopeless  until  at  least  two  years  have  passed.  Surgical  interference 
may  now  offer  some  hope,  but  great  care  must  be  exercised  that  such 
treatment  is  not  begun  too  early  so  that  it  interferes  with  the  possible 
natural  improvement  in  a  muscle  or  group  of  muscles.  It  is  well,  how- 
ever, to  call  in  the  orthopedist  early  in  order  that  severe  and  avoidable 
deformities  may  be  prevented. 


76  MU.NTilLV    liL'LLliTlX 


PREVENTION    OF   ACUTE    POLIOMYELITIS. 

The  measures  used  to  prevent  the  spread  of  acute  poliomyelitis 
must  be  based  upon  our  knowledge  of  its  modes  of  transmission,  and 
of  its  pathology,  in  so  far  as  it  relates  to  the  entrance  and  exit  of  the 
parasite  to  the  human  body  and  its  location  in  the  system.  Prophy- 
lactic measures  may  be  divided  into  general  and  special. 

GENERAL. 

The  first  necessity  is  that  physicians  shall  familiarize  themselves 
with  the  clinical  course  and  symptomatology  of  the  disease  so  that 
unrecognized  cases  will  be  lessened  in  number,  and  the  diagnosis  be 
made  as  early  as  possible.  Special  attention  should  be  paid  to  abortive 
and  atypical  cases,  and  all  such  cases  and  suspects  should  be  treated 
exactly  as  are  typical  cases.  With  the  medical  profession  alert  to  the 
diagnosis  of  acute  poliomyelitis,  the  first  step  in  the  prevention  of 
the  disease  is : 

I.  Notification.  The  State  Board  of  Health  has  made  acute 
poliomyelitis  a  reportable  disease,  and  physicians  or  heads  of  houses 
who  do  not  report  a  case  of  this  disease  promptly  to  the  health  officer 
are  subject  to  a  fine  not  to  exceed  one  hundred  dollars.  It  is  well  to 
attempt  to  interest  all  -physicians  in  the  disease  by  discussing  its  char- 
acteristics in  the  medical  meetings,  or  at  special  meetings  called  for 
the  occasion.  By  showing  physicians  the  necessity  for  prompt  and 
early  report  of  cases,  much  good  may  be  accomplished.  Health 
officers  should  see  that  all  cases  are  promptly  reported  and  should 
forward  such  reports  immediately  to  the  State  Board  of  Health.  If 
reports  are  not  promptly  submitted  to  this  office  much  time  may  be 
lost,  and  the  disease  be  allowed  to  spread  before  rational  preventive 
measures  are  instituted. 

Having  established  the  fact  that  the  disease  exists  in  the  com- 
munity, the  next  step  i?  to  so  control  each  case  that  the  danger  of  the 
spread  of  the  disease  shall  be  reduced  to  a  minimum.  It  has  become 
an  axiom  that  all  infection  should  be  centralized.  Therefore,  a  special 
hospital,  or  a  special  pavilion  in  an  already  established  hospital  should 
be  used,  to  which  all  cases  may  be  sent.  If  acute  poliomyelitis  is  an 
intestinal  disease  the  advantage  of  having  only  one  place  where  the 
sewage  must  be  properly  disinfected,  and  that  under  the  care  of  skiMed 
nurses  and  physicians  instead  of  many  scattered  localities  under  the 
care  of  careless  and  ignorant  nurses,  and  help,  is  very  obvious.  If 
the  disease  is  insect-borne  the  advantage  of  having  all  the  patients  in 
a  well-screened  hospital  rather  than  in  many  poorly  protected  houses 


OHIO    STATE    BOARD    OF    HEALTH.  77 

needs  no  comment.  Considering  acute  poliomyelitis  as  a  contagious 
disease  transmitted  by  the  naso-pharyngeal  secretions,  it  necessarily 
follows  that  the  number  of  contacts  in  a  well  regulated  hospital  is  less 
than  if  the  patients  were  allowed  to  remain  in  their  homes,  where  each 
case  would  be  a  focus  of  infection.  In  a  hospital  the  disease  may  be 
more  thoroughly  studied,  and  the  general  treatment  more  efficiently 
carried  out  than  in  the  home.  The  advantages  of  a  special  hospital 
for  the  care  of  patients  afflicted  with  acute  poliomyelitis  are  manifold. 
Such  a  hospital  should  be  free  to  all,  and  should  be  under  the  charge 
of  a  physician  skilled  in  this  disease. 

If  it  is  impossible  to  secure  such  a  hospital,  a  system  of  modified 
quarantine  must  be  'carried  out.  The  house  must  be  placarded  with  a 
large  card  conspicuously  placed,  and  bearing  on  it  the  name  of  the 
disease,  and  a  warning  to  the  public  not  to  enter.  Only  the  health 
board  or  its  representative  has  the  power  to  place  or  remove  such  a 
placard.  Having  the  home  quarantined,  the  next  step  is  to  secure  the 
proper  isolation  of  the  patient  and  attendant,  the  most  necessary  step 
in  the  prevention  of  acute  poliomyelitis. 

2.  Isolation.  A  large  airy  room  should  be  chosen,  and  all  un- 
necessary furnishings  removed.  Only  such  furniture  should  be  left 
as  may  be  easily  cleaned  and  disinfected.  It  is  well  to  have  a  trained 
nurse  in  attendance  on  all  cases,  but  if  the  patients,  because  of  poverty 
or  a  limited  supply,  are  not  able  to  secure  such  a  nurse,  only  one 
attendant  should  be  chosen.  This  attendant  must  not  care  for  other 
members  of  the  family  and  should  not  mingle  with  them  unless  proper 
care  of  hands,  nose  and  throat  is  taken,  directions  for  which  are 
detailed  later. 

3.  Exposures.  It  is  extremely  important  that  all  exposures^ 
especially  children  of  susceptible  age,  be  kept  under  close  observation. 
When  acute  poliomyelitis  occurs  in  a  community  all  physicians  should 
be  called  together,  and  a  committee  chosen  of  those  having  special 
knowledge  of  diseases  of  the  central  nervous  system.  It  will  be  the 
duty  of  this  committee  to  investigate  all  suspicious  cases,  to  aid  in  the 
diagnosis  of  doubtful  cases  and  to  observe  all  exposures.  It  is  very 
evident  that  unless  all  physicians  work  in  harmony  many  atypical 
cases  will  escape,  so  it  is  encumbent  upon  the  health  officer  or  who- 
ever assumes  charge  of  the  situation  to  do  all  in  his  power  to  form  an 
harmonious  unit  of  all  the  physicians  of  the  village  or  community,  and 
to  use  sufficient  publicity  to  insure  the  backing  of  all  right  minded 
members  of  the  laity.  In  larger  cities  dispensaries  and  clinics  may  be 
established  where  the  disease  may  l^e  studied  and  all  exposures  ob- 
served.    If  possible,  a  laboratory  shoulrj  be  establisherl  in  connection 


78  MONTHLY    BULLETIN 

with  these  clinics  or  dispensaries,  where  the  blood  and  cerebrospinal 
fluid  of  typical  and  suspicious  cases  may  be  submitted  for  examination. 
As  previously  pointed  out,  examination  of  these  fluids  may  be  of  help 
in  determining  the  diagnosis  or  in  excluding  other  conditions. 

4.  Public  Gatherings.  Public  gatherings  should  be  discouraged 
as  much  as  possible  in  the  presence  of  an  outbreak  of  acute  polio- 
myelitis. Children  at  least  should  be  excluded  from  such  gatherings. 
The  question  of  schools  may  be  decided  in  one  of  two  ways.  Either 
there  should  be  a  system  of  medical  inspection,  or  all  schools  should 
be  closed  when  the  disease  is  epidemic.  This  last  step  is  one  that 
should  only  be  taken  with  reluctance,  and  there  is  absolutely  no  need 
for  it,  as  an  efticient  system  of  inspection  can  be  organized  very  quickly. 
As  acute  poliomyelitis  does  not  usually  persist  after  October,  the  open- 
ing of  schools  may  only  have  to  be  delayed.  School  inspectors  should 
see  that  no  children  from  families  in  which  there  is  a  case  of  acute 
poliomyelitis,  are  allowed  to  attend  school  and  all  school  children 
should  be  inspected,  and  any  child  who  has  a  sore  throat  or  nasal 
catarrh  should  be  sent  home.  Any  child  with  a  temperature  should 
likewise  be  excluded.  The  importance  of  the  thermometer  in  an  in- 
spection of  this  kind  cannot  be  overestimated.  The  school  building 
should  be  placed  in  a  sanitary  condition  and  teachers  warned  to  be  on 
the  lookout  for  pupils  who  expectorate,  or  sneeze  without  the  use  of  a 
handkerchief.  It  is  needless  to  emphasize  that  all  common  drinking 
cups  and  common  towels  must  be  abolished.  The  general  regulations 
regarding  expectorating  in  public  places  should  also  be  strictly  en- 
forced. 

All  privies  situated  in  the  vicinity  of  houses  where  a  case  of  the 
disease  exists  should  be  placed  in  as  sanitary  a  condition  as  possible, 
and  their  contents  screened.  They  should  be  constructed  in  such  a  man- 
ner that  the  contents  are  easily  accessible  and  these  should  be  removed 
and  disinfected  frequently.  It  is  well  to  make  an  outbreak  of  acute 
poliomyelitis  the  occasion  for  enforcing  the  general  sanitary  regulations 
which  are  to  a  great  extent  so  poorly  enforced  and  so  generally  dis- 
regarded. 

The  streets  should  be  sprinkled  or  oiled  frequently  enough  to 
keep  down  the  dust,  as  some  obser^-ers  believe  that  dust  favors  the 
spread  of  acute  poliomyelitis. 

The  public  should  be  instructed  by  articles  in  the  press  and  cir- 
culars of  information,  regarding  the  danger  and  modes  of  the  spread 
of  acute  poliomyelitis.  It  is  wise  to  see  that  this  instruction  is  also 
given  to  the  higher  grades  in  schools.  If  the  above  steps  are  thor- 
oughly carried  out  they  will  constitute  a  model  campaign  of  preven- 


OHIO    STATE    BOARD    OF    HEALTH.  '  79 

tion   and   will   do   much   to   prevent   the   spread   not   only   of   acute 
poliomyelitis  but  also  of  the  more  common  communicable  diseases. 

SPECIAL   MEASURES. 

The  special  measures  necessary  for  the  control  of  acute  polio- 
myelitis have  to  do  with  the  care  of  the  patient.  In  the  Rockefeller 
Hospital  the  most  strict  precautions  were  used  and  the  disease  treated 
as  are  cases  of  smallpox  or  scarlet  fever.  All  patients  were  kept 
separate  from  other  cases,  and  remained  so  for  four  weeks  dating 
from  the  onset  of  the  disease.  When  they  were  sen'-  home  it  was 
urged  that  they  be  separated  from  other  children  as  much  as  pos- 
sible. Suspects  were  kept  in  separate  rooms  until  the  diagnosis  was 
made.  The  nurses  and  attendants  never  came  in  contact  with  other 
patients,  and  this  was  even  true  of  a  majority  of  the  physicians. 
Gowns  and  caps  were  worn  by  all  nurses,  attendants  and  physicians 
when  caring  for  patients,  and  the  hands  were  thoroughly  cleaned 
.with  soap  and  brush  and  disinfected  in  a  solution  of  corrosive  sublimate 
before  leaving  the  ward.  Only  one  visitor  was  admitted  to  the  ward 
for  each  patient  and  all  were  required  to  use  the  same  precautions 
as  were  practiced  by  thetiurses  and  physicians.  x\ll  clothing  and  other 
articles  coming  in  contact  with  the  patient  were  carefully  disinfected, 
and  when  the  room  was  empty,  fumigation  with  formaldehyde  gas  was 
practiced  and  the  floors  and  walls  thoroughly  scrubbed  with  soap  and 
water. 

These  measures  should  be  applied  to  the  individual  home  as  well 
as  to  the  hospital  ward.  The  discharges  of  the  nose  and  throat  should 
be  received  on  cloths  and  burned.  A  vessel  containing  a  solution  of 
corrosive  sublimate  (i-iooo)  should  be  used  to  receive  the  discharges 
of  the  bowels  and  bladder,  and  any  large  particles  should  be  broken 
up  with  a  stick  that  may  be  burned.  All  eating  and  drinking  vessels, 
and  linen  should  be  kept  separate  and  disinfected  by  fire  or  boiling 
if  possible.  In  addition  it  is  well  to  screen  the  patient  and  the  room 
must  be  screened  and  flies  excluded.  This  is  particularly  necessary  in 
houses  situated  near  stables  or  barns  where  animals  are  kept.  It 
should  be  emphasized  that  the  patient  is  the  center  of  infection  and 
all  measures  directed  to  render  all  his  discharges  innocuous. 

After  the  patient  is  well,  and  a  period  of  four  weeks  has  elapsed 
since  the  onset  of  his  disease,  other  children  of  the  family  should 
still  be  kept  at  home  for  a  period  of  three  weeks.-  This  has  been  rec- 
ommended in  France  and  by  many  observers  elsewhere.  It  is  well  to 
formulaic  thc^o  directions  in  the  form  of  rules  and  to  add  to  these 


80  MONTHLY    BULLETIN 

rules  certain  other  facts  that  the  whole  may  be  issued  as  a  circular  of 
information. 

CIRCULAR   OF    INFORMATION. 

The  virus  or  parasite  that  causes  acute  poliomyelitis  is  found 
only  in  the  human  body.  Individuals  may  have  the  disease  and  not  be 
paralyzed,  and  people  who  come  in  contact  with  cases  may  become 
carriers.  That  is,  they  carry  the  parasites  or  germs  but  show  no 
symptoms  of  the  disease.  For  this  reason  patients,  all  cases  of  sickness 
and  people  who  have  been  exposed,  should  be  avoided  when  acute 
poliomyelitis  exists  in  the  community.  Children  who  have  running- 
noses  and  sore  throats  should  seek  medical  relief.  The  rules  of  per- 
sonal hygiene,  such  as  cleanliness,  fresh  air  in  living  and  sleeping 
rooms,  and  proper  diet,  should  be  adhered  to  by  every  individual. 
When  you  have  a  case  in  the  house  the  following  rules  should  be 
observed. 

RULES  RECOMMENDED  FOR  THE  CONTROL  OF  ACUTE  POLIOMYELITIS.      . 

1.  Isolation  of  the  patient  and  screening  to  keep  out  insects. 
Domestic  animals  should  be  excluded  from  the  room. 

2.  Disinfection  or  destruction  of  all  discharges,  especially  the 
sputum  and  nasal  secretions  and  excretions  from  the  intestines.  Nurse 
and  physician  should  observe  the  same  precautions  regarding  their 
hands  and  clothing  as  in  attending  a  case  of  scarlet  fever. 

3.  A  modified  quarantine  should  be  observed.  Other  children 
in  the  family  should  certainly  be  excluded  from  school.  The  bread- 
winner may  be  allowed  to  work.  Four  weeks  should  be  the  minimum 
period  of  isolation  and  quarantine,  and  other  children  of  the  family 
should  keep  away  from  school  and  from  other  children  for  three  weeks 
after  the  patient's  recovery. 

4.  When  this  disease  is  present  in  a  community,  public  gath- 
erings which  children  will  attend  should  be  discouraged. 

5.  Members  of  the  family  and  those  exposed  should  use  a  gargle 
and  spray  consisting  of  1%  of  hydrogen  peroxide  under  the  direction 
of  their  physician. 

6.  As  soon  as  practicable  after  recovery  of  the  patient,  the  house 
should  be  disinfected  with  formaldehyde. 

7.  The  attention  of  physicians  should  be  directed  to  the  fact  that 
abortive  cases  are  often  associated  with  typical  cases,  and  the  same 
precautions  should  be  observed  with  such  cases. 

8.  Acute  poliomyelitis  (infantile  paralysis)  has  been  declared  by 
the  State  Board  of  Health  to  be  a  reportable  disease.     This  means  that 


OHIO    STATE   BOARD   OF    HEALTH,  81 

all  cases  must  be  reported  by  physicians  and  the  heads  of  families 
to  the  health  officer  and  by  the  health  officer  to  the^Secretary  of  the 
State  Board  of  Health. 

9.  Since  the  disease  is  infectious  prior  to  the  onset  of  paralysis, 
suspected  cases  should  be  reported  and  quarantined  until  the  exact 
nature  of  the  disease  is  known. 

Note  —  When  a  case  of  acute  poliomyelitis  is  reported  to  the 
State  Board  of  Health,  a  special  blank  for  detailed  information  will 
be  sent  the  physician  or  health  officer  and  it  is  requested  that  these 
blanks  be  carefully  filled  out  and  promptly  returned. 

It  is  not  altogether  clear  that  prophylactic  measures  have  in  the 
past  exercised  any  marked  influence  in  preventing  the  spread  of  acute 
poliomyelitis.  This  is  not  an  argument  to  discontinue  work  along  this 
line  but  a  stimulus  to  enforce  these  and  other  measures  more  string- 
ently, and  a  challenge  to  us  to  study  the  disease  more  closely.  As 
soon  as  further  and  more  accurate  data  has  been  collected  regarding 
the  sources  and  modes  of  infection,  the  methods  of  prevention  will  be- 
come more  efficient  and  the  control  exercised  over  the  spread  of  acute 
poliomyelitis,  stronger  and  more  universal. 

REFERENCES. 

1.  Rosenau  &  Brues,  Monthly  Bulletin,  Massachusetts  State  Board  of  Health, 

Sept.,  1912,  Vol.  7,  No.  9. 

2.  Anderson  &  Frost,  Public  Health  Reports,  Oct.  25,  1912,  Vol.  XXVH,  No. 

43. 

3.  Khng,  Pettersson  &  Wernstedt,  Report  from  the  State  Medical  Institute  of 

Sweden  to  the  XV  International  Congress  on  Hygiene  and  Demography. 

4.  Flexner  &  Clark,  Jour.  Am.  Med.  Assoc,  Jan.  18,  1913,  Vol.  LX,  No.  3. 

5.  Mortality  Statistics,  1911,   Bull.   112,  Dept.  of   Commerce,   Bureau  of  the 

Census. 

6.  Mortality  Statistics,  1910,   Bull.   109,   Dept.  of   Commerce,   Bureau  of  the 

Census. 

7.  Flexner  &  Noguchi,  Jour.  Am.  Med.  Assoc,  Feb.  1,  1913,  Vol.  LX,  No.  5. 

8.  Wickman,  Beitage  zur  Kenntniss  der  Heine-Medinschen  Krankheit,   Ber- 

lin, 1907. 

9.  Landsteiner  &  Popper,  Zeitschrift,   f.  Immunitatsforsch.     Orig.  1909,  Vol. 

2,  p.  877. 

10.  Flexner  &  Lewis,  Jour.  Am.  Med.  Assoc,  1909,  Vol.  53,  p.  1639. 

11.  Flexner,  Clark  &  Fraser,  Jour.  Amer.  Med.  Assoc,  Jan.  18,  1913,  Vol.  60, 

No.  3. 

12.  Flexner,  Simon,  Jour.  Amer.  Med.  Assoc,  Oct.  12,  1912,  Vol.  59,  No.  15. 

13.  Colmer,  G.,  Amer.  Jour.  Med.  Sciences,  1843,  Vol.  5,  p.  248. 

14.  Osgood  &  Lucas,  Jour.  Amer.  Med.  Assoc,  1911,  Vol.  57,  p.  495. 

15.  Starr,  M.  A.,  Acute  Poliomyelitis,  Albutt  &  Rolleston's   System  of  Med- 

icine, Vol.  7,  p.  623. 

•6    A.  P. 


82  MONTHLY   BULLETIN 

16.  Flexner,  Simon,  The  Huxley  Lecture,  Science,  Nov.  22,  1912,  Vol.  36,  No. 

934. 

17.  Infantile    Paralysis    in   Massachusetts   during    1910.     Report   by   the    State 

Board  of  Health. 

18.  Duchenne,  Cited  in  Osier's  Modern  Medicine,  Vol.  7,  p.  258. 

19.  Brues  &  Sheppard,  Jour.  Economic  Entomology,  Vol.  5,  No.  4. 

20.  Anderson  &  Frost,  Public  Health  Reports,  May  2,  1913,  Vol.  28,  p.  833. 

21.  Flexner  &  Clark,  quoted  in  Monograph  No.  4,  of  the  Rockefeller  Institute, 

June  24,  1912. 

22.  Lovett  &  Richardson,  quoted  in  Report  of  Infantile  Paralysis  fn  the  State 

of  Washington  during  1910.     Sept.  1,  1911. 

23.  Neustaedter  &  Thro,  New  York  Medical  Journal,  1911,  Vol.  XCIV,  p.  813. 

24.  Farrar,  Reginald,  Jour.  Royal  San.  Institute,  Oct.,  1912,  Vol.  33,  No.  9. 

25.  Frost,  W.  H.,  Amer.  Jour.  Pub.  Health,  March,  1913,  Vol.  3,  No.  3. 

26.  Flexner  &  Noguchi,  Jour.  Experimental  Medicine,  Vol.  28,  No.  4,  1913. 

27.  Charcot,  quoted  by  Oppenheim,  Lehrbuch  der  Nervenkrankheiten,   Berlin, 

1908. 

28.  Peabody,  Draper  and  Dochez,  Monograph  No.  4,  Rockefeller  Institute  for 

Medical  Research,  June  24,  1912. 

29.  Frost,  W.  H.,  Public  Health  Bulletin,  No.  44,  Feb.,  1911. 

30.  Striimpell,  quoted  in  Monograph  No.  4,  of  the  Rockefeller  Institute,  p.  73. 

31.  Medin,  Arch  med.  des.  enfants,  1898,  Vol.  1,  p.  257-321. 

32.  Anderson  &  Frost,  Jour.  Amer.  Med.  Assoc,  March  4,  1911,  Vol.  56,  p.  663. 

33.  Netter  &  Levaditi,  Compt.  rend.  Soc.  de  biol.  1910.  Vol.  68,  p.  617. 

34.  Gay  &  Lucas,  Arch.  Int.  Med.,  Sept.,  1910.  Vol.  6. 

35.  Clark,  Paul  F.,  Jour.  Amer.  Med.  Assoc.  August  3,  1912,  Vol  LIX. 


OHIO    STATE   BOARD   OF    HEALTH.  83 


DESCRIPTION  OF  PLATES. 
Plate  I. 
Stomoxys  calcitrans  Linn.,   (Female)  after  Austen. 

Plate  II. 

Figs.  1-3.  Musca  domestica  Linn. 
Figs.  4-6.  Fannia  canicularis  Linn. 
Figs,  7-9.     Stomoxys  calcitrans  Linn. 

After  Terzi  in  Rep.  to  Local  Govt.  Bd.  N.  S.  No.  5,  1909. 

Plate  III. 

Pig.  1.  Egg  of  Stomoxys  calcitrans  Linn. 

Fig.  2.  Lateral  view  of  anterior  segments  of  larva. 

Pig.  3.  Dorsal  view  of  anterior  segments  of  larva. 

Pig.  4.  Thoracic  spiracle  enlarged. 

Fig.  5.  Semi-diagrammatic  view  of  digestive  system. 

Pig.  6.  Semi-diagrammatic  view  of  salivary  glands  and  left  Malphigian  tube. 

Fig.  7.  Male  reproductive  organs. 

Fig.  8.  Female  reproductive  organs. 

Plate  IV. 

External  mouth  parts  of  Stomoxys  calcitrans  Linn. 

Pig.  1.  Median  longitudinal  section  of  skeleton  of  front  of  head  showing 
antennae,  maxillary  palpi  and  proboscis;  v,  vertex;  ant.,  antenna;  ar., 
arista;  mxp.,  left  maxillary  palpus;  ap.,  apodeme;  pr.,  proboscis;  I, 
II,  III,  segments  of  labium;  III,  showing  left  labellum. 

Pig.  2.  Proboscis  with  labium  removed ;  ap.,  apodeme ;  ph.,  pharynx ;  sd.,  sal- 
ivary duct;  g.,  lower  part  of  oesophagus  connecting  the  food  canal 
of  proboscis  with  the  pharnyx ;  I,  portion  of  base  of  labium;  lb., 
labrum ;   h.  p.,  hypopharynx. 

Pig.  3.  Transverse  section  of  base  of  proboscis.  I,  outer  wall  of  base  of  Seg- 
ment I  of  labium;  m.  c,  muscle  cells;  lb.,  section  of  labrum;  h.  p., 
section  of  hypopharnyx;  fc,  food  canal  formed  by  labrum  and  hypo- 
pharynx  combined;  s.  c,  salivary  canal  of  hypopharynx;  tr.,  trachea; 
k.,  keel  of  chitin  which  gives  rigidity  to  the  base  of  labial  groove. 

Pig.  4.  Base  of  proboscis  with  labium  removed  (adapted  from  Hansen's  fig.)  ; 
m.,  right  muscle  of  enlargement  of  salivary  duct  s.  d. ;  ph.,  pharnyx; 
g.,  tube  leading  to  pharnyx;  ap.,  base  of  apodeme;  lb.,  labrum;  h.  p., 
hypopharynx;  b.  h.  p.,  base  of  hypopharnyx;  k.,  part  of  keel;  see 
Fig.  3. 

Fig.  5.  Inner  surface  of  right  labellum;  vw.,  ventral  wall;  d.  m.,  dorsal  mar- 
gin; ct.,  chitinous  teeth;  cb.,  chitinous  blades;  h.,  hair-like  processes 
(adapted   from  Hansen's  fig.). 


84  MONTHLY    BULLETIN 


Plate  V. 

Photograph  of  large  breeding  cage.  A  lamp  chimney  to  remove  flies  from  the 
cage  is  shown  in  position.  Other  features  of  the  cage  are  described 
in  the  text. 

Plate  VI. 

Photograph  showing  method  of  feeding  Stomoxys  calcitrans  Linn.  These  flies 
bite  readily  through  the  fine  meshes  of  the  netting  covering  lamp  chimney. 
The  abdomen  is  selected  as  the  skin  is  soft  and  readily  pierced  in  this  situation. 

Plate  VII. 
Fig.     1.     Paralysis  of  the  left  hind  limb.     (After  Romer). 
Fig.     2.     A  trace  of  paralysis  of  the   right  hind  limb.      (After   Romer.) 

Plate  VIII. 

Fig.  1.  Photograph  of  a  young  girl  recovering  from  infantile  paralysis.  A 
residual  paralysis  of  the  left  side  of  the  face  is  shown.  This  case 
was  included  in  the  study  of  the  disease  in  Ohio. 

Fig.  2.  Photograph  showing  paralysis  of  the  right  shoulder  two  years  after 
the  occurrence  of  the  disease. 


OHIO    STATE    BOARD    OF    HEALTH. 


85 


/  \ 


P-, 


86 


MONTHLY    UULI.KI  IN 


CQ 


OHIO    STATE    BOARD    OF    HEALTH. 


87 


--  u,nt 


r-W. 


--e.d. 


r.s.----4 


ex%. 


[•la  IK     Ml. 


d8 


MONTHLY    BULLETIN 


-It. 


Plate  IV. 


OHIO    STATE   BOARD   OF    HEALTH. 


g 
a 


90 


MONTHLY    BULLETIN 


OHIO    STATE    BOARD    OF    HEALTH. 

Plate  VII. 


91 


I'ig.  I. 


l-uj    II. 


92 


Mux  I  lll.^    i:li.ij;'1"ix 


Plate   VI 11. 


l^'R.    I. 


^^^^^^E^ 

1 

■ 

ml' 

' 

1  l^H 

■• 

'4 

Fig.   II. 


DISEASES   REPORTABLE   IN  OHIO. 


Report  the  following  Communicable  Diseases  to  Local  Health  Officer:— 

TUBERCULOSIS. 

Pulmonary  (Consumption). 

All  Other  Forms. 
DIPHTHERIA  AND   MEMBRANOUS  CROUP. 
MEASLES. 
SCARLET  FEVER. 
CHICKENPOX. 
WHOOPING  COUGH. 
TYPHOID  FEVER. 
SMALLPOX. 

ACUTE   POLIOMYELITIS    (INFANTILE   PARALYSIS) 
EPIDEMIC   CEREBRO-SPINAL   MENINGITIS     (BRAIN   FEVER). 
OPHTHALMIA   NEONATORUM. 
TRACHOMA  (GRANULATED  LIDS). 
ASIATIC  CHOLERA. 
BUBONIC   PLAGUE. 
TYPHUS  FEVER. 
YELLOW  FEVER. 


Report  Occupational  Diseases  to  State  Board  of  Health:— 

LEAD  POISONING. 
PHOSPHORUS  POISONING. 
ARSENIC  POISONING. 
BRASS  POISONING. 
WOOD-ALCOHOL  POISONING. 
MERCURY  POISONING. 
ANTHRAX  INFECTION. 
COMPRESSED-AIR  ILLNESS. 

ANY  OTHER  AILMENT  OR  DISEASE,  CONTRACTED  AS  A  RESULT 
OF  THE   NATURE   OF  THE   PATIENT'S   EMPLOYMENT. 


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